literature review help seeking behaviour

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Factors associated with help-seeking behaviour among individuals with major depression: A systematic review

Julia luise magaard.

1 Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

Tharanya Seeralan

Holger schulz, anna levke brütt.

2 Department of Health Services Research, Carl von Ossietzky University, Oldenburg, Germany

• Conceptualization: ALB HS JLM.
• Data curation: JLM TS.
• Formal analysis: ALB JLM TS.
• Funding acquisition: ALB.
• Investigation: JLM TS ALB.
• Methodology: JLM ALB HS TS.
• Project administration: ALB HS JLM.
• Resources: HS ALB.
• Supervision: HS.
• Validation: JLM ALB TS.
• Visualization: JLM TS.
• Writing – original draft: JLM.
• Writing – review & editing: ALB HS TS.

Associated Data

All relevant data are within the paper and its Supporting Information files.

Psychological models can help to understand why many people suffering from major depression do not seek help. Using the ‘Behavioral Model of Health Services Use’, this study systematically reviewed the literature on the characteristics associated with help-seeking behaviour in adults with major depression. Articles were identified by systematically searching the MEDLINE, EMBASE and PsycInfo databases and relevant reference lists. Observational studies investigating the associations between individual or contextual characteristics and professional help-seeking behaviour for emotional problems in adults formally diagnosed with major depression were included. The quality of the included studies was assessed, and factors associated with help-seeking behaviour were qualitatively synthesized. In total, 40 studies based on 26 datasets were included. Several studies investigated predisposing (age (N = 17), gender (N = 16), ethnicity (N = 9), education (N = 11), marital status (N = 12)), enabling (income (N = 12)), need (severity (N = 14), duration (N = 9), number of depressive episodes (N = 6), psychiatric comorbidity (N = 10)) and contextual factors (area (N = 8)). Socio-demographic and need factors appeared to influence help-seeking behaviour. Although existing studies provide insight into the characteristics associated with help seeking for major depression, cohort studies and research on beliefs about, barriers to and perceived need for treatment are lacking. Based on this review, interventions to increase help-seeking behaviour can be designed.

Introduction

Major depression is a common mental disorder and one of the leading causes of health impairment worldwide [ 1 ], resulting in serious impairment of functioning and decreased quality of life [ 2 , 3 ]. To treat major depression depending on severity, American and European guidelines (e.g. [ 4 , 5 ]) recommend treatment options as psychotherapy, pharmacotherapy, or a combination of both. Despite the availability of effective treatment options, researchers continue to find that a significant number of individuals suffering from major depression do not seek professional help. Using studies on service utilization rates for major depression in community-based surveys, Kohn, Saxena [ 6 ] reported that the percentage difference between number of people needing treatment for major depression and number of people seeking professional help ranged between 15.9% (12 month, Florence) [ 7 , 8 ] and 83.9% (current, UK) [ 9 ]. They estimated that the median untreated rate for depression is 56.3% worldwide [ 6 ].

Various psychological models have been used to explain variations in help-seeking behaviour among populations, such as the Self-Regulation Model [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ]. From the sociological perspective models like the Pescosolido’s Network Episode Model [ 13 ], Kadushin’s theory about why people go to psychiatrists [ 14 ] and the Behavioral Model of Health Services Use [ 15 ] were specifically constructed to explain help-seeking behaviour. The ‘Behavioral Model of Health Services Use’ suggests that people’s predisposition to use services, factors which enable or impede the use of services and people’s need of care predict and explain health behaviours like use of health services [ 15 ]. According to the model, all health behaviours influence health related outcomes. The model includes feedback loops to demonstrate that outcomes can affect health behaviours, predisposing, enabling and need factors and health behaviours can influence predisposing, enabling and need factors. In the current version of his ‘Behavioral Model of Health Services Use’, Andersen [ 15 ] distinguishes between contextual and individual characteristics influencing service utilization and health-related outcomes ( Fig 1 ). The model asserts that contextual and individual characteristics consist of predisposing, enabling and need factors [ 15 ]. Individual characteristics are measured at the individual level, whereas contextual characteristics are measured at an aggregate level (e.g., families, communities, national health care system). Contextual characteristics include health organizations and provider-related factors as well as community characteristics [ 15 ]. At the individual level, a person’s beliefs (e.g., attitudes towards health services), demographic characteristics (e.g., age) and social factors (e.g., education) define his or her predisposition to use health services. Additionally, the availability of financial resources to pay for services as well as organizational factors (e.g., regular source of care, means of transportation to care) enable or impede the use of health services at the individual level. In the “Behavioral Model of Health Service Use” it is not clearly defined if social relationships and social support are considered as predisposing or enabling factors. We agree with Andersen’s argumentation that social support can facilitate or impede help-seeking behaviour and therefore serves as an enabling resource [ 15 ] whereas the social structure including family situation predisposes help-seeking. Furthermore, perceived and evaluated need influences help-seeking behaviour. Professional judgement about people’s health and need for treatment is represented by evaluated need whereas perceived need includes people’s perspective on their own health [ 15 ]. The model has frequently used in studies and systematic reviews (e.g. [ 16 , 17 , 18 ]). According to validity, associations between different individual characteristics and services use were found empirically. However, causal conclusions cannot be drawn from analyses on the basis of mainly cross-sectional data (e.g. [ 16 ]). Individual characteristics of the current model can be expanded to include predictors of help-seeking behaviour like treatment and illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ].

The current review focusses on contextual and individual characteristics as well as use of personal health services and relations between characteristics and use of personal health services (printed in bold).

In recent years, several quantitative studies have used Andersen’s model to investigate the factors influencing professional help-seeking behaviour among individuals suffering from depression (e.g. [ 17 , 18 ]). Additional quantitative studies on this subject have been conducted without referral to Andersen’s model (e.g. [ 19 ]). However, a systematic review of these findings has not been performed. The only existing review [ 20 ] was published 14 years ago and focused on studies using heterogeneous definitions of depression or depressive symptoms and help-seeking behaviour, finding that the help-seeking behaviour of individuals with depression or depressive symptoms was influenced by age, ethnicity, social support and clinical and psychiatric factors. Further studies focussed on specific populations [ 21 ] or specific factors associated to help-seeking [ 22 , 23 ]. Recently, a qualitative synthesis of interview studies about help-seeking behaviour among people with depression was published [ 24 ].

The purpose of this review was to apply a theoretical framework to investigate the individual and contextual characteristics associated with professional help-seeking behaviour for emotional problems in adults with major depression. Therefore, the current review addresses two questions: (1) Which characteristics associated with help-seeking behaviour in adults suffering from major depression are investigated in the literature? (2) How are these characteristics related to help-seeking behaviour in adults suffering from major depression?

In addition to including new literature, this review expands upon previous reviews in two ways: first, it embeds the findings within the ‘Behavioral Model of Health Services Use’ framework and integrates aspects of different models. By systematically reviewing observational studies using standardized diagnostic instruments to assess major depression, this review aims to synthesize the results of studies assessing help-seeking behaviour in a homogeneous population.

To the extent that they were applicable to observational studies and to the qualitative synthesis of results, the methods and results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 25 ] ( S1 Appendix ) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement [ 26 ]. No review protocol exists.

Search strategy

Two researchers (JLM, ALB) searched the MEDLINE, EMBASE and PsycInfo electronic databases in February 2017 (09.02.2017) using key words and a standardized vocabulary (e.g., MeSH) presented in S2 Appendix . These terms aimed to represent the concepts of ‘Depression’ and ‘Help-Seeking’. The search was restricted to ‘human’ and ‘English or German’. Additionally, the EMBASE search was restricted to ‘article’, and the search in PsycInfo to ‘all journals’.

Study selection

After excluding double hits, the title and abstracts of all articles (published in English or German) identified through the electronic search were screened to exclude clearly irrelevant articles. Two researchers (TS, JLM) independently screened the title and abstracts of 150 records. If at least moderate agreement was achieved (Kappa ≥ .41) [ 27 ], the remaining records were screened by JLM. Additionally, the reference lists of the relevant studies and reviews identified in the electronic search were manually examined.

In the second step, the full texts of all potentially relevant studies were independently reviewed by two researchers (TS, JLM). The decision to include studies was based on a priori defined inclusion criteria (IC) ( S3 Appendix ).

Study design

To identify the factors associated with help-seeking behaviour, we relied on observational quantitative studies because randomization of these influencing factors is not possible. Therefore, cohort, case-control and cross-sectional studies were included (IC 1), but intervention studies were excluded unless they retrospectively assessed help-seeking behaviour at baseline.

To investigate the factors of interest in a population with a comparable depression status, studies reporting on the help-seeking behaviour of individuals with a major depressive episode or major depression disorder were included (IC 2). To ensure the validity of the diagnoses, a sample or subsample with formally diagnosed major depression disorder or a major depression episode according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Statistical Classification of Diseases (ICD) or Research Diagnostic Criteria (RDC) was required (IC 3). We included studies investigating adult populations (IC 4) with depressive subsamples of population-based datasets to ensure that the samples included individuals not seeking care (IC 5).

Based on the guidelines and in accordance with other reviews on help-seeking [ 16 , 23 , 28 ], we defined professional help-seeking as contacting a health practitioner or service for mental health reasons at least once or receiving therapy including primary care and specialized care in outpatient and inpatient settings in a defined time period (IC 6). To ensure the homogeneity of our outcome, we decided to exclude studies assessing lifetime help seeking. Studies had to include results on the factors influencing help-seeking behaviour (IC 7).

We included studies if they fulfilled all of the inclusion criteria. If there were disagreements about the in- or exclusion of a study, the decision was discussed until consensus was reached (JLM, TS, ALB).

Data extraction and synthesis

The study characteristics, factors associated with help seeking, results and methodological quality were extracted by JLM and TS. Qualitative data synthesis was performed to illustrate which influencing factors were investigated and to discuss heterogeneous findings (e.g., adjusted and unadjusted results) from samples in heterogeneous contexts (e.g., countries, health care systems). Therefore, JLM and TS classified all investigated variables into individual and contextual predisposing, enabling and need factors according to the ‘Behavioral Model of Health Service Use’ [ 15 ]. Data synthesis was performed by vote counting because of the heterogeneity of settings, measures, adjustments and the number of investigated variables. Therefore, measures (e.g., odds ratios, chi-square, and regression coefficients) of the association between each variable and help seeking were grouped into significant positive, significant negative and non-significant results and were listed for each variable. Any disagreements between JLM and TS were discussed until agreement was reached. We documented if and which potential confounding variables were adjusted for in the analyses.

Assessment of methodological quality

Two researchers (JLM, TS) evaluated the methodological quality of all of the included studies. Because of the high level of homogeneity in study design, we considered only criteria with variance between studies. Consequently, three criteria were used ( S4 Appendix ). Two criteria of 14 from the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [ 29 ] were selected to examine internal validity (Q1 and Q2, S4 Appendix ). We added one criterion about the recruitment of a cohort from the Critical Appraisal Skills Programme [ 30 ] to focus on external validity (Q3, S4 Appendix ). A score of 1 was awarded for each criterion adequately fulfilled, with a potential score ranging from 0 (poor) to 3 (excellent). No studies were excluded because of poor quality rating.

Study characteristics

Altogether, 40 studies based on 26 datasets were included in the systematic review (see Fig 2 for an overview of the search process). The study characteristics are summarized in S5 Appendix . The 26 included datasets comprised 24 cross-sectional studies, one case-control study [ 31 ] and one cohort study [ 32 ]. The years of publication for these studies ranged from 1987 [ 33 ] to 2016 [ 34 ]. In 24 of the 26 datasets, the help-seeking behaviour of individuals with major depression was assessed in population-based samples within a certain region or country. The exceptions included a study investigating white-collar professionals from a specific corporation [ 35 ] and a study investigating the relatives and spouses of people seeking treatment for mental disorders and matched controls [ 31 ]. Most datasets were collected in the US (N = 10) and Canada (N = 8). The other datasets were collected in Finland (N = 3), Ethiopia (N = 1), Mexico (N = 1), Estonia (N = 1), Netherlands (N = 1) and Europe (N = 1). The sample sizes ranged between 102 and 18,927 participants with major depression [ 36 ].

Quality of studies

The study quality was rated as ‘good’ (60%) for more than half of the studies, ‘excellent’ for one study [ 32 ], ‘fair’ for 35% of the studies, and ‘poor’ for one study [ 35 ]. S5 Appendix displays the ratings of methodological quality.

Individual predisposing factors

Thirty-nine studies and all 26 datasets reported results on individual characteristics, as shown in S6 Appendix .

Five studies assessed stigma and help-seeking beliefs; feeling comfortable with seeking help [ 37 , 38 ] and having the intention to seek help [ 38 ] were positively associated with help-seeking behaviour. Negative attitudes towards antidepressants were negatively related to help-seeking behaviour [ 39 ]. Lin and Parikh [ 38 ] reported no significant associations between help seeking and beliefs about improving through or without professional care and feeling embarrassed about seeking help. This finding is inconsistent with Diala, Muntaner [ 37 ], who found that participants who said they would be embarrassed if their friends knew they were getting mental health care were less likely to use it than others. Aromaa, Tolvanen [ 39 ] found no association between help-seeking behaviour and prejudices against mentally ill people. However, they found that a stronger desire for social distance was negatively related to help seeking. Boerema, Kleiboer [ 34 ] reported that own negative attitudes towards people with depression are negatively related to help-seeking, whereas participants’ beliefs about how other people think about depression was unrelated to help-seeking.

Kleinberg, Aluoja [ 19 ] found that a higher external locus of control was associated with increased help seeking.

Demographic factors

The associations between gender and help seeking were analysed in 16 datasets. In three US samples [ 18 , 32 , 40 ] and one Finish sample [ 39 ], being female was positively related to help-seeking behaviour. Sussman, Robins [ 33 ] reported the same association only among white Americans, not among black Americans. An association between gender and help-seeking was not found in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 40 , 43 – 45 ], American [ 31 , 35 ], Finnish [ 46 , 47 ], Netherlands [ 34 ] or Mexican [ 48 ] samples.

The association between age and help seeking was analysed in 17 different datasets and was mainly computed comparing different age groups. In eight datasets, age was significantly associated with help-seeking behaviour. Two of these studies reported a positive association between age in years and help seeking [ 31 , 39 ]. In the other five datasets, being middle-aged was significantly related to higher help-seeking rates [ 32 , 41 , 49 – 51 ].

Social factors

The associations between help-seeking behaviour and social factors are shown in S6 Appendix . Results were available for educational status (N = 11 datasets), ethnicity (N = 9 datasets), family and living situation (N = 15 datasets) and employment (N = 4 datasets)

The associations between help seeking and education in individuals with major depression were significantly positive or non-significant in the eleven datasets. For example, in three datasets, more years of education and a higher degree were positively associated with help-seeking behaviour after adjusting for clinical and socio-demographic variables [ 32 , 42 , 44 , 52 ]. After adjusting for clinical and socio-demographic variables, this positive association remained significant only in the Canadian dataset [ 40 ] and the US dataset [ 53 ].

Differences between help seeking by ethnic group were assessed in four Canadian and five US datasets. Belonging to a different ethnic group was defined differently between the studies. Differences in help-seeking between different ethnic groups were reported in seven studies [ 18 , 32 , 33 , 37 , 40 , 54 , 55 ]. For example, black Americans [ 55 ], African Americans [ 18 , 37 ], Mexican Americans [ 18 ], and ethnic minorities [ 40 ] had lower rates of seeking help compared to whites. No differences were reported between the help-seeking behaviours of people born in Canada and of Canadian migrants [ 44 ], except that lower rates of help-seeking were observed in a group of Chinese immigrants compared to a group of Canadians born in Canada [ 52 , 54 ]. The results from the ‘National Survey of American Life’ (NSAL) showed that although African Americans reported higher rates of seeking help than Caribbean Blacks, this difference was only significant in a sample of adults with severe or very severe symptoms [ 56 ] and was not significant in a sample of adults with mild to moderate symptoms [ 56 ] or in a subsample of mothers [ 57 ]. Sussman, Robins [ 33 ] reported that blacks had lower odds of seeking help than whites only in people with less severe depression.

Eight [ 33 , 34 , 38 , 40 – 42 , 44 , 52 ] out of 15 datasets found no association between help-seeking behaviour and marital status or living as married. In addition, no significant associations were reported for cohabitation [ 19 , 47 ], household size [ 19 ] or pregnancy [ 58 ]. However, four studies showed that being married or living as married was negatively associated with help-seeking behaviour [ 17 , 31 , 35 , 59 ]; in contrast, Chartrand, Robinson [ 32 ] found the opposite relationship. Gadalla [ 52 ] reported that single mothers with adult children had the lowest odds of seeking treatment in comparison to other women.

Individual enabling characteristics

Financial aspects were addressed in ten datasets, focusing mainly on income or household wealth. In Spanish respondents from the ‘European Study of the Epidemiology of Mental Disorders’ (ESEMeD), the low to average income group was negatively related to help seeking compared to the highest income group [ 41 ]. Diala, Muntaner [ 37 ] found a similar association in respondents from the ‘National Comorbidity Survey’ (NCS). Conflicting results were found in male respondents from the CCHS 1.2, in which help-seeking was positively related to a lower adjusted household income [ 17 ]. All other studies reported non-significant results regarding this association [ 18 , 31 , 32 , 38 , 40 , 42 , 44 , 52 , 53 ]. In the ‘Collaborative Psychiatric Epidemiology Survey’ (CPES), health insurance coverage doubled the odds of any use of depression therapy in the past year [ 18 ], while in the American samples in the ‘Joint Canada/United States Survey on Health’, this association lost significance in the multivariate model [ 40 ].

Regarding the influence of organizational factors on help-seeking behaviour, findings on the availability, accessibility and acceptability of care were available from the CCHS 1.2 [ 17 ]. Additionally, findings on the influence of having a regular medical doctor were available in the ‘Joint Canada/United States Survey on Health’ [ 40 ]. Availability, including waiting times and help not available in the area, was positively related to help-seeking among female Canadian respondents, whereas accessibility and acceptability were not related to help-seeking [ 17 ].

Social support was addressed in three datasets. In the CCHS 1.2, social support and help seeking were positively related in women only [ 17 , 52 ]. Although social support was not directly associated with help-seeking behaviour in the Estonian health survey, emotional loneliness was associated with increased help seeking among depressed persons with an external locus of control [ 19 ]. Dew, Bromet [ 35 ] found that receiving social support during the index episode was negatively related to help seeking, whereas receiving recommendations from others to seek professional help was positively related to help seeking.

Individual need characteristics

Studies on the need factors influencing help-seeking behaviour often focused on the severity of depression (14 datasets), psychiatric comorbidity (11 datasets), duration of episode (9 datasets), subjective disability (5 datasets), number of depressive episodes (6 datasets), somatic comorbidity (6 datasets), and presence of certain depressive symptoms (7 datasets) ( S6 Appendix ). Illness and symptom based need factors were assessed through structured interviews or questionnaires and were defined as professional judgements about people’s mental health status and therefore can be allocated to evaluated need, according to the “Behavioral Model of Health Services Use” [ 15 ]. Specifically, severity of depression was positively related to help-seeking in seven of the 16 datasets [ 31 , 39 , 40 , 46 , 47 , 60 , 61 ]. In addition, a longer duration of illness was positively related to help-seeking behaviour in six datasets [ 31 , 34 , 35 , 40 , 46 ] and was non-significantly related in three datasets [ 33 , 38 , 53 ]. After adjusting for socio-demographic and clinical variables, having more than one major depressive episode was no longer significantly associated with help seeking in the ‘Ontario Health Study’ (OHS) [ 38 , 53 ]. Furthermore, in three other datasets, no significant association occurred [ 31 , 35 , 53 ]. However, in the group of black US participants [ 33 ] and female Canadians [ 52 ], there was a significant positive association. Having trouble concentrating [ 31 , 35 , 46 ] and suicidal thoughts or ideation [ 31 , 35 , 46 , 52 ] were positively related to help-seeking behaviour. Conversely, three studies found no significant results for the latter association [ 32 , 38 , 53 ].

Psychiatric comorbidity was assessed in eleven datasets, and somatic comorbidity in seven ( S6 Appendix ). Having comorbid generalized anxiety disorder [ 17 , 44 , 47 ] or a panic disorder [ 31 , 62 ] was positively related to help-seeking behaviour. Interestingly, after adjusting for several clinical and socio-demographic factors, having a generalized anxiety disorder, agoraphobia or panic disorder in the previous 12 months was significantly related to higher help-seeking rates in OHS respondents but not in NCS respondents [ 53 ]. In contrast with the findings from the Ontario study, Lin and Parikh [ 38 ] found no significant differences analysing the same dataset. Moreover, comorbid phobic disorders were not related to help-seeking behaviour [ 31 ].

Chen, Crum [ 36 ] showed that people suffering from major depression and substance dependence were more likely to seek help than people suffering from major depression only. Other findings indicate no significant difference in help-seeking behaviour with comorbid substance dependence disorder [ 17 , 38 , 44 , 63 ] or alcohol or drug abuse [ 31 ]. Having any additional mental disorder was positively related to help-seeking behaviour in one [ 41 ] of four relevant studies [ 38 , 44 , 64 ].

Suffering from chronic somatic disorders was significantly associated with higher help-seeking rates in two datasets [ 17 , 44 , 52 , 65 ]. However, in five datasets, this association was non-significant [ 34 , 38 , 40 , 41 , 60 ]. Demyttenaere, Bonnewyn [ 65 ] found that people with depression who had comorbid painful physical symptoms had lower rates of help seeking than those without these comorbid symptoms. In older people from the same dataset, this association was not significant [ 66 ].

Contextual characteristics

Studies on the contextual characteristics of help seeking in individuals with major depression have focused on region or different countries. Living in an urban or rural area was not related to help-seeking behaviour in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 44 ] or American [ 32 ] samples. Additionally, no differences in help-seeking behaviour were found between the American and Canadian samples [ 40 ] or between the Francophone Canadian and European samples [ 67 ]. Differences in individuals’ help-seeking behaviour between different regions of the US were found in one [ 32 ] of two studies [ 31 ].

This paper aimed to systematically review the individual and contextual characteristics associated with professional help-seeking behaviour in adults suffering from major depression based on the ‘Behavioral Model of Health Service Use’. Several studies investigated the association between help-seeking behaviour and individual characteristics, such as socio-demographic predisposing factors (e.g., age, gender, ethnicity, education, and family status), enabling factors (financial situation/income) and need factors (e.g., severity of depression, comorbidity, and duration and number of episodes). Some studies focused on beliefs (n = 4) (predisposing factors), social support (n = 4), organization (n = 3) (enabling factors), and context (n = 8) (e.g., urban vs. rural, country) and help-seeking behaviour. No study focusing on need for mental health treatment was included. Similarly, studies investigating help-seeking behaviour for different diseases based on the ‘Behavioral Model of Health Services Use’ examined characteristics similar to those of the studies included in our review [ 16 ].

Based on the current review, it appears that several factors may influence the likelihood that an individual suffering from major depression will seek professional help.

Predisposing factors that seem most likely to decrease help-seeking behaviour in individuals with major depression are, being young or elderly, being male, belonging to certain ethnic groups and having a lower educational status. Although these groups may be at a higher risk for not seeking professional help for major depression, the reasons for this higher risk need to be clarified. Certain structural or attitude-related barriers to seeking care among individuals in these groups may explain the findings. For instance, synthesizing qualitative studies, Doblyte and Jiménez-Mejías [ 24 ] identified attitudinal barriers for help seeking among depressed man, ethnic minorities and young adults: They concluded that help seeking is a threat to hegemonic masculinity, that the fear of disclosure and being judged was strongest among young adults and that ethnic minorities were more willing to keep depression within family [ 24 ]. Apart from attitudinal barriers, structural barrier like cultural inappropriateness of interventions could explain lower help-seeking rates among ethnic minorities [ 24 ].

The majority of studies reported no association between income and help-seeking behaviour. A possible explanation for this finding might be that income as an indicator is not sensitive enough to detect socioeconomic differences in the use of health care services [ 68 ]. Regardless, accounting for the financing of health care systems it is necessary to interpret these associations [ 15 ].

There is some evidence that the severity of depression, longer and more depressive episodes and the presence of anxiety disorders are related to higher help-seeking rates. These findings are consistent with those on help-seeking behaviour in individuals with depressive symptoms or depressive disorder [ 20 ]. However, as these findings were mainly based on retrospective cross-sectional studies, it remains unclear whether individuals affected by more severe depression are more likely to seek help. It is possible that individuals receiving treatment perceive their condition to be more severe than individuals without treatment. Qualitative findings indicate that the first hypothesis is more likely, because professional help-seeking is seen as the “final step”, because it “damages one’s self-definition” [ 24 ].

Based on the reviewed literature, the effects of additional individual predisposing factors such as attitudes on help-seeking behaviour and enabling factors like social support remain unclear. These psychosocial variables are mentioned in the ‘Behavioral Model of Health Service Use’, but which factors influence help-seeking behaviour in what way is not specified. Nonetheless, the initial findings show that social support might be associated with help-seeking behaviour [ 17 , 35 , 52 ]. Therefore, it might be worth distinguishing between informational social support (e.g., recommending seeking care) and emotional social support and investigating the interactions with other psychological concepts such as locus of control. Although the former could facilitate help seeking (e.g. [ 35 ]), the latter may only be associated with help seeking in certain populations (e.g., in individuals with an external locus of control [e. g. 19]). Regarding the influence of beliefs, feeling comfortable seeking care [ 37 , 38 ] was positively associated with help-seeking, whereas having negative beliefs about antidepressants and having a stronger desire for social distance from people who are mentally ill [ 39 ] and having negative attitudes towards them [ 34 ] might have a negative impact on help-seeking behaviour. Within the ‘Health Beliefs Model’ [ 11 ], these beliefs could be considered the perceived benefits and barriers to taking action. Henshaw and Freedman‐Doan [ 69 ] conceptualised help-seeking for mental illnesses using this model and examined the role of fears about treatment and stigma as psychological barriers. The desire for social distance from mentally ill people is known to be an indirect measure of stigmatizing beliefs towards people belonging to this group, and a dissonance between these negative stereotypes and the preferred self can impede help-seeking for mental health problems [ 23 ]. Fears about antidepressant treatment could be a particular problem if practical or psychological barriers to seeking psychotherapy exist.

As evidenced by the findings presented in the results section, several factors of the ‘Behavioral Model of Health Service Use’ seem to be not validated through the systematic review. For instance, mainly no associations between certain predisposing factors (e.g. employment status), enabling factors (e.g. income, organisation), need factors (e.g. somatic symptoms, general health) and help-seeking were identified.

Practical implications

The studies included in this review revealed that men, young and elderly adults, and people of certain ethnicities as well as individuals with a lower educational status with major depression are at risk of not seeking help, and these populations could be addressed in individually tailored interventions to increase help-seeking. In a review of randomized controlled trials, the majority of help-seeking interventions for depression, anxiety and psychological distress targeted young people [ 28 ]. In that review, Gulliver, Griffiths [ 28 ] provided some evidence that mental health literacy interventions (e.g., delivering destigmatisation information and/or providing information about help-seeking sources) can be effective in improving help-seeking attitudes. Mental health literacy is defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [ 70 ]. However, this positive association could not confirmed for help-seeking behaviour for these interventions [ 28 ]. According to Doblyte and Jiménez-Mejías [ 24 ] who stressed out the role of hegemonic masculine identity and its influence in limiting men’s help seeking behaviour, educational campaigns for primary care providers can facilitate communication between male patients and GPs. Additionally a slighter entrance into care can be achieved. In this spirit, trainings which increase GPs intercultural competence and awareness of cultural differences regarding e.g. illness definition should also be considered [ 24 ]. However, further research on interventions that increase help-seeking intentions and behaviour among individuals suffering from major depression is needed.

Limitations

The results of this review should be considered in light of several limitations. First, the vast majority of the studies reviewed were conducted in the US and Canada, which reduces the external validity of the findings. Second, the synthesis of results was limited because of the heterogeneity of the studies. Although the samples were homogenous regarding the formal diagnosis of major depression, the studies differed in terms of the samples’ age, gender and ethnicity as well as the health care systems affecting the participants. According to the ‘Behavioral Model of Health Service Use’, these contextual characteristics directly influence service utilization and indirectly influence service utilization through individual characteristics [ 15 ]. In addition, the results included different levels of adjustment. Third, reliable conclusions concerning whether a factor causes help-seeking behaviour were not possible, because the large majority of the studies used cross-sectional designs and retrospective data. Fourth, there was a lack of studies that quantitatively investigated the influence of individuals’ beliefs and perceptions on their help-seeking behaviour. Finally, because of the heterogeneous measures and adjustment methods used, a quantitative synthesis was not appropriate.

Plea for consideration of the subjective perspective in help-seeking behaviour

The focus on socio-demographic and clinical variables in the reviewed literature is understandable, as the majority of the studies utilized secondary datasets, thus limiting the variables available for analysis. Nevertheless, it is important to obtain information on the subjective perspective to better understand the complex process of help seeking. Furthermore, including this perspective could provide insight into the associations between certain socio-demographic variables and help seeking. For instance, several studies have already been conducted to shed light on depressed men’s lower help-seeking rates (for review see [ 21 ]) and on men’s delays in medical and psychological help-seeking (for review see [ 71 ]). Specifically, embarrassment, distress or anxiety related to using health care services, need for emotional control, the perception of symptoms as minor and poor communication with health professionals were identified as barriers for help-seeking among men [ 71 ]. Although the ‘Behavioral Model of Health Service Use’ [ 15 ] does not focus on this subjective perspective, it is explicitly included in the predisposing contextual individual beliefs and implicitly included in perceived need . Psychological models such as the Self-Regulation Model of Illness Behavior [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ] focus on the individual’s perspective in the help-seeking process. According to these models, illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ] influence help-seeking behaviour. For instance, a qualitative analysis using the Self-Regulation Model found that primary care patients with depression who did not seek treatment believed that the treatment would not be effective, that depression would be short-lived and that it would not affect their daily lives [ 72 ]. Accordingly, it is promising to focus on psychological variables that affect the decision-making process of seeking help to better predict behaviour.

Future directions for research

We suggest that future quantitative research on help-seeking behaviour among individuals suffering from major depression should focus more on the individuals’ perspective and include psychological theories as a framework for understanding the help-seeking process. Additionally, the influence of illness beliefs, treatment beliefs, anticipated stigmatization and perceived need for mental health care on help seeking may be worth investigating. Future research should provide insight into the associations between predisposing, enabling and need factors to improve the understanding of the complex process of help seeking. Therefore, the characteristics identified in the literature should be further considered.

Future prospective cohort studies on the causal relations between predisposing, enabling and need factors and help-seeking behaviour among individuals suffering from major depression should also be conducted. Measuring predisposing beliefs, perceived barriers, clinical variables, and perceived need prior to assessing help-seeking behaviour is important because these characteristics can change due to treatment and over time.

This review found that the associations of help-seeking behaviour with socio-demographic predisposing (e.g., age, gender, ethnicity, education, and family status), enabling (financial situation/income), need (e.g., severity of depression, comorbidity, and duration and number of episodes) and contextual factors were investigated in several studies. Gender, age, education, ethnicity, marital status, severity of depression, duration and number of depressive episodes, and comorbid anxiety disorders appeared to influence help-seeking behaviour. Further research investigating the influence of these characteristics on help-seeking behaviour by individuals suffering from major depression in prospective cohorts and research specifically focused on beliefs, social support, organizational factors and perceived need for treatment would address a significant gap in the literature. A better understanding of the process of help-seeking by individuals suffering from major depression and improved knowledge of the factors that influence this process are important for identifying groups at risk of failing to seek adequate professional help and for improving their access to depression care.

Supporting information

S1 appendix, s2 appendix, s3 appendix, s4 appendix.

Q1 and Q2 from the ‘Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” [ 29 ] Q3 from the Critical Appraisal Skills Programme [ 73 ].

S5 Appendix

ws = whole sample; MDE = major depressive episode; MDD = major depressive disorder; NR = not reported; DIS = Diagnostic Interview Schedule; WHO-CIDI / CIDI = World Health Organization’s composite international diagnostic interview; SFMD = Short form for major depression; SF = Short form; UM = Short Form (University of Michigan) ESEMeD = European Study on the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Study; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; CPES = Collaborative Psychiatric Epidemiology Survey; NSAL = National Survey of American Life; NCS = National Comorbidity Survey; NCS-R = National Comorbidity Survey–Replication; NLAAS = National Latino and Asian American Study; JUCSH = Joint Canada/US Survey of Health; NSDUH = National Study on Drug Use and Health; OHS = Ontario Health Study; ENHS = Ethiopian National Health Survey; NPHS = National Population Health Survey; ENHS = Ethiopian National Health Survey.

S6 Appendix

If adjusted and unadjusted results were reported in the same study for the same variable, only the adjusted results were listed in the table. + = significant positive association between characteristic and help-seeking behaviour;— = significant negative association between characteristic and help-seeking behaviour; Ø = no significant association between characteristic and help-seeking behaviour; x = significant differences between different groups; ESEMeD = European Study of the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Survey on Mental Health and Well Being; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; NSDUH = National Survey on Drug Use and Health; NCS = National Comorbidity Survey; OHS = Ontario Health Study; EHS = Estonian Health Survey; CPES = Collaborative Psychiatric Epidemiology Survey.

Acknowledgments

This study as not funded and part of the dissertation of Julia Luise Magaard (JLM). However, Anna Levke Brütt (ALB), Tharanya Seeralan (TS) and JLM received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression. The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper. The authors declare that they have no competing interests. The authors wish to thank Mr. PD Dr. Levente Kriston for valuable and constructive comments on conduction of systematic reviews. We thank American Journal Experts (AJE) for English language editing.

Funding Statement

This study was not funded and part of the dissertation of Julia Luise Magaard (JLM). However, JLM, Anna Levke Brütt (ALB) and Tharanya Seeralan (TS) received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression (DFG BR4859/3-1). The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper.

Data Availability

• Research article
• Open access
• Published: 11 June 2020

What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review

• Antonia Aguirre Velasco 1 ,
• Ignacio Silva Santa Cruz 2 ,
• Jo Billings 3 ,
• Magdalena Jimenez 4 &
• Sarah Rowe   ORCID: orcid.org/0000-0003-1072-6182 3  

BMC Psychiatry volume  20 , Article number:  293 ( 2020 ) Cite this article

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Increasing rates of mental health problems among adolescents are of concern. Teens who are most in need of mental health attention are reluctant to seek help. A better understanding of the help-seeking in this population is needed to overcome this gap.

Five databases were searched to identify the principal barriers, facilitators and interventions targeting help-seeking for common mental health problems in adolescents aged 10–19 years. The search was performed in June 2018 and updated in April 2019. Two independent screening processes were made using the eligibility criteria. Quality assessment of each study was performed, and findings summarised using a narrative synthesis.

Ninety studies meet the inclusion criteria for this review for barrier and facilitators ( n  = 54) and interventions ( n  = 36). Stigma and negative beliefs towards mental health services and professionals were the most cited barriers. Facilitators included previous positive experience with health services and mental health literacy. Most interventions were based on psychoeducation, which focused on general mental health knowledge, suicide and self-harm, stigma and depression. Other types of interventions included the use of multimedia and online tools, peer training and outreach initiatives. Overall, the quality of studies was low to medium and there was no general agreement regarding help-seeking definition and measurements.

Most of the interventions took place in an educational setting however, it is important to consider adolescents outside the educational system. Encouraging help-seeking should come with the increased availability of mental health support for all adolescents in need, but this is still a major challenge for Child and Adolescent Mental Health Services. There is also a need to develop shared definitions, theoretical frameworks and higher methodological standards in research regarding help-seeking behaviours in adolescents. This will allow more consistency and generalisability of findings, improving the development of help-seeking interventions and ensuring timely access to mental health treatments.

Peer Review reports

Young people present with the highest prevalence of mental health disorders compared to individuals at any other stage of the lifecycle [ 1 ], with up to 20% of adolescents likely to experience mental health disorders [ 2 ]. Mental health has been defined as “a state of wellbeing in which and individual realizes of his/her abilities, can cope with normal stresses of life ( …) and is able to make a contribution to his/her community” [ 3 ]. Around 50% of mental health conditions start before the age of 14 [ 4 ] and the onset of 75% of cases is before the age of 18 [ 5 ]. The most common diagnoses are depression and anxiety [ 6 ] and around 25% of young people experience psychological distress [ 7 ]. Depression is one of the principal causes of illness and disability in teenagers, and suicide is the third most common cause of death among older adolescents [ 4 ]. Mental health problems can significantly affect the development of children and young people [ 4 ] having an enduring impact on their health and social functioning in adulthood [ 8 ]. Adolescents experiencing mental health conditions may face several challenges such as isolation, stigma, discrimination and difficulty in accessing health services [ 2 ]. However, 75% of adolescents with mental health problems are not in contact with mental health services [ 9 ], the primary reason being reluctance to seek help [ 1 , 10 , 11 ].

Help-seeking for mental health problems necessitates communicating the need for personal and psychological assistance to obtain advice and support. Rickwood and Thomas’ (2012) define help-seeking for mental health problems as “an adaptive coping process that is the attempt to obtain external assistance to deal with mental health concerns” [p.180, 12]. This includes both formal (e.g., health services) and informal (e.g., friends and family) sources of help. However, adolescents most in need of psychological help are those least likely to look for it [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. One of the biggest challenges in adolescent mental health is ensuring that at-risk individuals are linked with the appropriate support [ 14 ]. Understanding barriers and facilitators to help- seeking is fundamental for the development of interventions and programmes to support adolescents with mental health problems.

Rickwood et al., (2005), investigated the main barriers and facilitators of help-seeking for mental health problems in young people. They found that lack of emotional competence, negative beliefs about help-seeking and stigma were the most prominent barriers. Conversely, emotional competence, previous positive experiences with health professionals and mental health literacy, were the main facilitators [ 15 ]. Gulliver et al., (2010) performed a systematic review of the available literature at that time, finding similar results; however, they stated that stigma was the most prominent barrier for seeking for help in young people [ 1 ]. Another systematic review was made by Rowe et al., (2014), focused on in help-seeking for adolescent self-harm. They found that in addition to stigma, negative reactions from others related to confidentiality breaches and being seen as an “attention seeker” were the most relevant obstacles [ 10 ]. While interesting, these previous reviews do not address the help-seeking barriers and facilitators of most common mental health troubles among adolescents, nor include interventions targeting these. Rickwood, Deane et al., (2005) only included depressive symptoms, personal emotional problems and suicidal thoughts and Rowe et al. (2014), only focused on adolescent self-harm. The most complete review published by Gulliver and colleagues (2010) is almost 10 years old and need of updating.

Adequate and effective interventions that promote help-seeking are necessary for enhancing prevention, early detection, timely treatment and recovery from mental health problems [ 14 ]. Previous systematic reviews on interventions targeting help-seeking reveal some promising results in regard to enhancing mental health literacy [ 16 ] and a significant positive overall effect of these interventions in improving help-seeking for mental health problems [ 17 ]. Nonetheless, these reviews do not focus on adolescent populations and only one includes randomised controlled trials (RCT).

The primary aim of this review is therefore to provide an update of the literature on barriers and facilitators of adolescent mental health help-seeking including formal and informal sources of help, with the inclusion of interventions targeted at improving this. We will focus on common mental health problems, including depression, anxiety, suicidal thoughts, self-harm, emotional distress, among other personal-emotional symptoms. The secondary outcome is to examine any significant differences between age and sex. Understanding the difficulties around help-seeking behaviours and facilitating access to timely and effective treatment is essential for preventing the escalation of mental health problems among adolescents.

For the purpose of this review, help-seeking was defined as the action of actively searching for help for mental health problems, including informal (family, friends) or formal (GP, mental health professionals, etc.) sources, based on interpersonal and social abilities [ 11 ]. “Adolescents” were people aged 10 to 19 years, as defined by the World Health Organisation [ 4 ]. Despite the increasing debate regarding the age of adolescence [ 18 ], this definition was considered as appropriate for our study as it is accepted by international organisation such as OMS and UNICEF. Also, we considered this age range more homogenous and comparable in terms of lifecycle experiences and challenges that would be reflected in help-seeking behaviours and intentions. This review was prospectively registered on PROSPERO (CRD42018096917) and reported in accordance with the PRISMA guidelines [ 19 ]. The search terms were developed using the PICO structure, then expanded using MeSH terms and combined using Boolean operators. Four databases were selected including MEDLINE®, Embase, PsycINFO, and Web of Science, as well as the search engine Google scholar, identified as an optimal database combination [ 20 ]. Grey literature from the mentioned databases was also included and a search was carried in Open Grey. An initial version of the proposal for this study was reviewed by the McPin Foundation. The feedback was considered in the developmental stage, in order to evaluate the relevance and reception of the protocol by Patient and Public Involvement (PPI) organisations.

We included studies published in English, Spanish and French and focused on identifying barriers, facilitators and interventions targeting help-seeking behaviours for mental health problems in adolescents, specifically depression, anxiety, suicidal ideation, emotional distress and general symptoms of mental illness. Other mental health problems such as psychosis, anorexia, among others were excluded, because we decided to focus on most prevalent mental health problems which share a more similar help-seeking process. Regarding barriers and facilitators, we included studies published after 2010 since a previous systematic review on the topic was published then [ 1 ]. We did not include any limit regarding year of publication for help-seeking interventions. All study designs were considered, including feasibility studies and study protocols. We excluded studies that referred to young people over the age of 19 or children under 10 years old. When study populations included adolescents outside of the established age range, the paper was included if over 50% of the individuals in the sample were within the 10–19 years category or if separate outcome data was provided for the participants in this age range. Studies meeting the inclusion criteria and including parents in their sample were also considered. Finally, other exclusion criteria were articles written in other languages, or if the intervention did not explicitly target help-seeking behaviours or was not related to mental health conditions (Appendix S1 ) (Table  1 ).

The search was performed in June 2018 and updated in April 2019. The results were exported to EndNote X8 and duplicates were removed. Titles and abstracts were screened by one author (AA) at the first stage. At a second stage, two authors (AA and IS) checked the full articles using the pre-determined inclusion and exclusion criteria. A third member of the research team (MJ) was available to solve discrepancies. Disagreement on 12 studies was attributed mainly to differences concerning the definition and measurement of help-seeking and was resolved in a discussion with a third author (MJ) not involved in the process of screening. Authors were contacted when relevant information was missing or when we could not find the articles retrieved by the databases. Reference list of all included studies were screened in case we found other studies relevant to our review. Data were extracted using a predefined form, which allowed the research team to identify the main characteristics of each study. This process was executed by one author (AA) after a complete review of the included papers. For the first question, data extraction focused on identifying barriers and facilitators and for the second question, intervention and effect size when reported. We created an additional form to extract data regarding the secondary outcome (age and sex). For the quality assessment, we used the Joanna Briggs Institute Critical Appraisal Checklist [ 21 ] and the Mixed Methods Appraisal Tool (MMAT) [ 22 ], which were appropriate due to the variety of study designs included in this review; both have been previously validated [ 23 , 24 ]. The Joanna Briggs tool has a number of checklists to evaluate the main features of each study design. We used the checklist for cross-sectional studies, RCT, quasi-experimental studies and qualitative studies. Each checklist had a number of items to evaluate the most relevant aspect of the specific design (e.g: for RCT was allocation to treatment groups concealed? Were treatment groups similar at the baseline?). After completing the checklist an overall quality appraisal score was calculated to provide a measure (low, medium and high) of the quality of each study. The MMAT included a similar checklist but is specific to mixed method study reviews. Overall study quality was not used as an exclusion criterion because we opted to be overly inclusive and provide a thorough overview of help-seeking in adolescents. Results have been summarised using a narrative synthesis. We identified the most relevant features regarding help-seeking barriers, facilitators and interventions in our data. These features were grouped into themes that capture the essential aspects regarding the main outcome of this review. With this information we developed a preliminary synthesis of the results organizing the themes so that patterns regarding the main barriers, facilitators and interventions were identified. Finally, we explored previous evidence on the topic and explore the relationship between the included studies. This allowed us to explore the influence of heterogeneity and the robustness of the preliminary synthesis [ 25 ]. Due to the heterogeneous nature of the studies included, a meta-analysis was not conducted. The quality of each study was not used as an exclusion criterion or impacted the weight given to each study in the narrative synthesis. This over-inclusive criteria allowed us to have an overall picture not only regarding help-seeking barriers, facilitators and interventions, but also the methodological quality of the available evidence.

Two independent searches were carried out during June 2018 and then updated in April 2019. A total of 90 studies were included in this review, combining both barriers and facilitators ( n  = 54) and the intervention ( n  = 36) questions. PRISMA diagrams displaying the number of papers retrieved and the process of selection of the included studies is available in Figs.  1 and 2 . Regarding the inter-rater reliability for this review, the agreement between the researchers screening the papers was high, with a 85% accuracy and 95% precision (Kappa = 0.954). Adolescents identified a range of formal and informal help-seeking options across studies, such as GPS, psychologists, psychiatrists, teachers, social workers (formal), and friends, family, sporting coaches, and online communities (informal). Regarding question 1, most of studies focused on identifying barriers and facilitators towards formal sources of help, whereas intervention studies had a wider variety of sources of help, depending on help-seeking behavior attempted to promote.

Prisma 2009 Flow Diagram. Question 1: Help-seeking barriers and facilitators

Prisma 2009 Flow Diagram. Question 2: Help seeking interventions

Question 1: help-seeking barriers and facilitators

Fifty-four studies that reported barriers and/or facilitators including a total of 56,821 participants were considered in the narrative synthesis (Table  2 ). Most of the studies ( n  = 18) were conducted in Australia, followed by the United States ( n  = 12) and the United Kingdom ( n  = 5). The majority of the studies were cross sectional ( n  = 36) [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ], thirteen studies were qualitative [ 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ] and six used a mixed-method design [ 75 , 76 , 77 , 78 , 79 , 80 ]. Three PhD dissertations and one conference abstract were included in the grey literature. The age ranged from 8 to 26 years old. Three articles included adolescents and their parents, while one article included just adolescents’ mothers.

The majority of studies were conducted in educational settings, such as schools ( n  = 24) and tertiary education ( n  = 11) focusing in non-clinical samples. Sixteen studies included participants from other community settings and two studies were conducted in mental health care facilities. Among the studies that include actual help-seekers ( n  = 7), the most common reason for seeking help was suicidal ideation, self-harm, depressive symptoms, and general mental health concerns (e.g., anxiety/nervousness/fear). Therefore, the conclusions drawn by the majority of the articles were based on help-seeking intentions rather than actual behaviours, since the participants were not experiencing mental health problems and focused on hypothetical scenarios.

Help-seeking barriers

Stigma is defined as the fear of being socially sanctioned or disgraced leading to hiding or preventing certain actions or behaviours, including the misreporting of mental health problems [ 81 ]. More than half of the included studies ( n  = 30) made reference to this and other negative attitudes towards mental health problems as the main obstacle to help-seeking behaviours in adolescents. Of these, twenty-five studies referred to stigma as the primary obstacle, describing it through different concepts such as, “stigma”, “fear of stigmatisation”, “community stigma”, “perceived stigma” and “self-stigma”. Other negative attitudes towards mental health problems included shame, fear, and embarrassment.

Family beliefs

The second most mentioned barrier was associated to adolescents’ family beliefs toward mental health services and treatment ( n  = 15). Barriers related to problem with communication and distrust towards health professionals, negative past experiences with mental health services, and believing that the treatment is not going to be helpful. This was especially true for studies including immigrant and refugee populations, which referred to cultural barriers including mistrust of mental health diagnosis and practitioners, and lack of cultural sensitivity in services as a significant barrier.

Mental health literacy

Mental health literacy refers to the ability to use mental health information to recognise, manage and prevent mental health disorders and make informed decisions about help-seeking and professional support [ 82 ]. Almost one-third of the articles ( n  = 14) referred to problems related to mental health literacy as a significant barrier including poor recognition of mental health conditions (self and others) and lack of awareness of available sources of help.

Adolescents’ attitudes towards help-seeking revealed a perceived need of self-sufficiency and autonomy which were recognised as a relevant barrier in twelve studies, as well as fears of confidentiality breaches.

Other help-seeking barriers

To a lesser extent, problems regarding service and personnel availability and other structural factors (such as cost, transportation and waiting times) were mentioned as obstacles to help-seeking ( n  = 8). This was a significant barrier for studies including rural and immigrant populations, and in studies that included parents in their sample. Six studies focused on the relationship between symptomatology and help-seeking. These found that higher levels of psychological distress, suicidal ideation and depressive symptoms were linked to lower help-seeking behaviours.

Help-seeking facilitators

Of the 56 included studies, 19 also referred to facilitators of help-seeking behaviours. Mental health literacy and prior mental health care were the most cited facilitators for help-seeking for mental health problems ( n  = 10). Specifically, timely access to mental health was facilitated by having a previous positive experience with mental health services or help-seeking, being familiar with the sources of help, and good symptom and problem recognition. Higher engagement with the community and having a trusting and committed relationship with relevant adults such as parents, schoolteachers and counsellors also facilitated seeking help among adolescents. Further details of the included articles are available in Table 2 .

Secondary outcomes

Few studies identified a significant difference when comparing younger and older adolescents in relation to barriers and facilitators to help-seeking, with no conclusive findings being reached. Some findings suggested that older adolescents tended to establish to feel more comfortable with people with mental health issues [ 83 ] and had less help-seeking fears [ 40 ]. In contrast, younger adolescents had greater knowledge about professional sources of help [ 34 ]. Only one study found a significant difference between ages regarding help-seeking, with younger adolescents reporting higher intentions of seeking help [ 60 ].

Twenty-four studies examined possible gender differences in help-seeking barriers and facilitators. Seven studies did not find significant differences between genders [ 28 , 39 , 40 , 42 , 46 , 51 , 69 ]. One study reported higher help-seeking intentions in males experiencing suicidal intentions [ 60 ] and two studies found that females perceived more overall barriers [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ]. However, this may be related to higher rates of females seeking help for mental health problems compared to males [ 31 , 33 , 37 , 42 , 48 , 53 , 58 , 61 , 76 ]. Studies reviewed did not evidence convincing differences between gender in relation to help-seeking.

Question 2: help-seeking interventions

Thirty-six studies on interventions targeting help-seeking behaviour, including a total of 28,608 participants, were summarised in the review (Table  3 ). Most of intervention studies were conducted in Australia (14) and the United States (14), followed by Canada (4) and United Kingdom (3). All studies were conducted in educational setting including high school ( n  = 35) and college ( n  = 1). The majority of studies developed interventions for non-clinical samples, and their focus was the prevention of mental health problems and the promotion of healthy coping strategies via help-seeking behaviours. Outcomes varied between help-seeking intentions, attitudes and behaviours. Almost half of the studies focused on the effectiveness of the interventions, while sixteen were feasibility or pilot trials and study protocols. Most of the studies used a quasi-experimental design ( n  = 21) followed by randomised controlled trials ( n  = 15). The age of participants ranged from 11 to 19 years old, although one study that included participants under 29 years old was incorporated as more than half of the sample were adolescents. Interventions were delivered using four main methods: psychoeducation, outreach interventions, multimedia tools and peer leader training.

Types of intervention

Psychoeducation.

Most of studies ( n  = 23) used psychoeducation and classroom-based interventions. Although all the interventions focused on encouraging help-seeking behaviours, the emphasis and content differed among them, including general mental health topics, suicide and depression awareness and stigma.

Five studies developed programmes based on the notion that promoting mental health awareness could enhance mental health literacy and promote help-seeking [ 84 , 85 , 86 , 87 , 88 ]. Four interventions targeting help-seeking for suicide were identified within five studies [ 89 , 90 , 91 , 92 , 93 ]. Five interventions explicitly targeted help-seeking for depression in school-based settings their focus being to educate the school population about adolescent depression and thereby encourage help-seeking [ 94 , 95 , 96 , 97 , 98 ]. Two studies evaluated the effectiveness of an intervention combining depression awareness and a suicide prevention programme promoting early identification and self-referral [ 99 , 100 ]. Six classroom-based interventions addressing stigma were identified, two of which used psychoeducation to overcome myths regarding mental illness [ 101 , 102 ] and four focused on providing interpersonal contact with people with mental health conditions in order to improve acceptance and increase help-seeking intentions [ 103 , 104 , 105 , 106 ].

Outreach interventions

Three studies used outreach interventions to target mental health help-seeking [ 107 , 108 , 109 ]. These aim to establish contact with adolescents who may be experiencing psychological and emotional distress in order to help them get the attention they need and increase their access to health services. They were based on the Building the Bridges to General Practice (BBGP) programme, developed by Wilson et al. (2005), a programme that aims to target help-seeking obstacles for physical and psychological problems by promoting contact between high school students and general practitioners [ 110 ].

Multimedia interventions

Six types of multimedia interventions have been developed to address some of the difficulties of reaching an adolescent population, such as fear of confidentiality breaches, stigma and self-reliance [ 111 , 112 , 113 , 114 , 115 ]. The interventions included interactive films to engage students with mental health related topic and online platforms providing personalised information regarding the decision-aids process.

Peer training interventions

Peer training interventions are focused on the training of peers who act as active agents of change and social interactions incorporated into the daily activities within the school environment [ 116 ]. All three programmes followed similar principles concerning improving the climate around mental health problems, promoting social connectedness, and challenging norms and behaviours associated with help-seeking [ 117 , 118 , 119 , 120 ]. “Peer leaders” acted as a link between the student population and mental health literacy, promoting the acceptability of seeking for help for mental health problems.

Further details of the included articles are available in Table 3 .

No studies referred to significant differences concerning the effectiveness of help-seeking interventions when comparing ages. No significant gender differences were identified regarding the effectiveness of the help-seeking interventions [ 89 , 101 , 103 , 111 ]. However, before the intervention¸ females tended to have higher mental health literacy and more adaptive attitudes regarding mental health problems [ 90 , 111 ], including greater help-seeking knowledge and intentions [ 107 , 112 , 113 ].

Effectiveness

The main goal of this review was to describe the interventions targeting help-seeking in adolescents and therefore did not include an analysis of their effectiveness. Almost half of the included studies were study protocols and feasibility studies, so effect sizes were not reported. However, some findings are worth mentioning.

Four studies which looked at effectiveness of the interventions focused on psychoeducation about depression found a significant effect in increasing help-seeking. King et al., [ 99 ] identified that there was an increase in future help-seeking behaviours after the interventions and that this was maintained at 3 months’ follow-up ( t  = 4.634/ p  < .001). Strunk et al., [ 100 ] found a significant increase of help-seeking ( p  < 0.0005); however, this was not sustained at follow-up ( p  = 0.014). Robinson et al., [ 95 ] found that the intervention group was more likely to seek help at post-test (Odds ratio (95% C.I) =3.48 (1.93, 6.29), p  < 0.0001) and Ruble et al., [ 96 ] found increased intention of help-seeking from others after the intervention ( t  = 13.658/ p  < 0.0001.).

The three studies that looked at the effectiveness of stigma reduction identified positive effects of the intervention on help-seeking. Two studies [ 101 , 104 ] found a significant reduction in self-stigma surrounding seeking help after the intervention ( p  < 0.05) and one study [ 103 ] found a significant effect of the intervention in help-seeking intentions (Wilks’ Λ = .942, F (4,417) = 6.428, p  < 0.001).

Finally, all the studies that focused on outreach found a significant effect of the intervention in help-seeking intentions. One detected an increase in intentions at 3 months follow-up ( F (2,217) = 3.04/ p  < 0.05) [ 108 ], Rughani [ 107 ] found short terms improvements in help-seeking intentions (F (14,225) =1.87 p  < .03) and Wilson [ 109 ] found a significant effect in the intention of seeking help for psychological problems after the intervention (F (2,598) = 4.31 p  < 0.01).

Quality assessment

The majority of the studies were low to medium quality with moderate to high risk of bias. Most of the cross-sectional studies did not state a clear inclusion and exclusion criteria and did not consider possible confounders affecting the interpretation of the outcome. Regarding qualitative research, the most common problem was linked to sample size and the difficulty of providing a clear strategy to address the subjectivity of the authors in the interpretations of the data. Mixed method studies presented some inconsistencies in addressing specific components of both quantitative and qualitative traditions, and in the process of integrating both approaches. Regarding intervention studies, it was difficult to identify to what extent the groups were similar at baseline. Although some studies included baseline measures of demographic information, most of them did not consider confounders or other factors influencing effectiveness, and some studies did not have any baseline measures. Also, few studies included follow-up and the ones that did, had high attrition rates and short follow-up periods (up to 6 months); therefore, it is not possible to attribute a long-lasting effect to the interventions. Quasi-experimental studies acknowledge possible selection and sample bias. Randomised controlled trials presented difficulties in terms of the blinding of the research team and participants at different stages of the process.

Overall there was inconsistency regarding the measurements of help-seeking, with most of the studies focusing on help-seeking intentions, which is not necessarily related to future behaviours. Moreover, many studies did not use valid and reliable instruments for measuring help-seeking. This is especially true for the experimental studies since most of them developed tools focused on their intervention rather than standardised help-seeking measures. Finally, most of the studies only used self-report measures, increasing the risk of bias of the findings. We did not assess the quality of study protocol, feasibility studies and pilot studies.

Question 1: barriers and facilitators

This review focused on identifying barriers, facilitators and interventions targeting help-seeking behaviours in adolescents. Consistent with previous findings [ 1 ], the most prominent barrier identified was stigma. Negative attitudes and beliefs about mental health services and professionals was the second most prominent barrier. Trusted and strong relationships with possible gatekeepers (teachers, parents, GPs, health professionals, etc.) and prior positive help-seeking experience were the most cited facilitators.

Few studies related symptom severity with help-seeking. Of those that did, higher symptomatology was associated with lower help-seeking intentions and behaviours. This is in line with previous studies suggesting that teens who are most in need are less likely to seek help [ 1 , 11 , 15 ]. It is possible that the nature of mental health symptoms such as self-blame, emotional distress, difficulty in speaking to others and diminished cognitive ability contribute to lower help-seeking behaviours. Adolescents with higher symptom severity may be even more vulnerable experiencing difficulties with the help-seeking process in areas such as identifying the need for professional assistance or fear of stigmatisation. This could be due to higher rates of isolation and exclusion from their peers. Increasing mental health literacy among this population may provide a way of improving social support between peers [ 121 ].

There are structural barriers affecting the help-seeking process that go beyond attitudes, for example, costs, waiting times and transportation. These barriers were not among the most prominent reasons cited in the research review; however, this may be related to the limited amount of studies that included parents’ perceptions. A previous review, which focused on the parents of children and adolescents, concluded that structural barriers were the most relevant [ 122 ]. This suggests that adolescents are less worried about the practical implications of accessing help for mental health problems and are more affected by being attitudinal barriers, but that structural barriers may be more relevant to parents.

Key facilitators to help-seeking should be considered when creating new interventions such as trusted relationships with gatekeepers, and familiarisation with the help-seeking process. However, the lack of studies focusing on facilitators precludes many conclusions being drawn. The majority of studies used sub-clinical samples and/or hypothetical help-seeking scenarios rather than asking genuine help-seeker with mental health problems who could refer to the real circumstances leading them to ask for help. More research including young people who have sought help from services would be useful in understanding the idiosyncrasies of this process.

These findings provide a useful overall picture of the relevant factors influencing the help-seeking process in adolescents. However, the included studies did not share a clear definition and framework regarding help-seeking. A wide range of tools were used to measure help-seeking, varying in their validity and reliability, and also in the constructs they measured. This limits the generalisability of the findings and our understanding of the help-seeking process. Rickwood & Thomas (2012) have proposed a framework regarding help-seeking, identifying the different parts of the process, sources of help, types of help and main concerns [ 15 ]. In the future, sharing such a framework could be a useful means to reach a general agreement regarding the definition of help-seeking and its components.

Question 2: interventions

The types of interventions varied considerably and included classroom-based psychoeducation, outreach interventions, multimedia and online-based interventions and peer training. Among classroom-based psychoeducation interventions, the most effective ones were those focused on prompting help-seeking through addressing depression and stigma. All peer outreach interventions had a significant effect in improving help-seeking intentions, thus showing promising results. In sum, addressing stigma, mental health literacy, and attitudes towards mental health services could be beneficial in terms of promoting help-seeking.

Most of the intervention studies included in this review did not investigate mechanisms of change with regards to help-seeking behaviour. The relevance of studying underlying mechanisms and practical requirements related to the functionality of interventions has been previously discussed [ 123 ], and most of the interventions included in this review did not refer to these processes. Identifying such mechanisms could help understand how interventions work, enlightening and optimising the process of decision-making and design [ 93 ]. Adolescence is a period essentially characterised by emotional, behavioural, hormonal, and neuronal changes [ 124 , 125 ]. Interventions congruent with the developmental stages may be useful to target age-appropriate factors.

It is important to mention that few intervention studies referred in detail to the implementation process and the main issues they encountered; however, the studies which did refer to this, found significant barriers. School administration issues, the difficulty of obtaining parental consent and attrition rates for the follow-up measures were one of the main difficulties regarding the implementation [ 93 , 97 , 102 , 115 ]. Teacher’s support and engagement with the intervention were also described as a barrier in the implementation process for some studies [ 85 , 93 , 114 ]. Most of studies concluded that implementation strategies should consider the reality and challenges of each school. For this the theme of contextualization is fundamental and the specificities of the process of implementation (planning, engaging, executing, reflecting and evaluating) [ 126 , 127 ].

All interventions were conducted within an educational setting. Special attention should also be paid to young people outside of the educational system, who are particularly vulnerable in terms of economic and social deprivation [ 128 ]. Around one in five children and adolescents are out of school according to the UNESCO [ 129 ], with psychosocial factors appearing to obstruct traditional educational trajectories [ 130 ]. Health and mental health conditions have a relevant role in terms of absenteeism and truancy [ 131 ]. Adolescents experiencing symptoms of depression and anxiety or in charge of a chronically sick relative can be more prone to avoid school and stay at home. These children can be even more vulnerable and harder to reach, and there is a lack of collaborative effort attempting to overcome this situation. Encouraging partnerships between the health and educational systems, community settings, youth detention centres, among other institutions providing social care, should be promoted with the purpose of supporting mental healthcare and provision for young people [ 132 ].

Encouraging adolescents to seek help for mental health problems is a key priority however, this does not resolve the discrepancy between needs and resources worldwide [ 132 , 133 ]. “Mental health services for children and adolescents have internationally been poorly understood, underfunded and even neglected by governments” [p.92, 134]. This may be associated with the lack of a general understanding of this population’s needs (including developmental issues), and the “implementation gap”, referring to the challenges of translating evidence to health service development and practice [ 134 ]. Simultaneously, focusing on increasing help-seeking and service availability for children and adolescents is necessary to reduce the global burden of disease and protect the future health of this population [ 125 , 135 ].

Limitations

This review has a number of limitations. First, only one author performed the data extraction and critical appraisal of papers therefore the data analysis is at risk of some subjectivity. Second, there is an increasing debate regarding the age that adolescence comprises, with some suggesting the age should be extended to 10 to 24 years old [ 17 ]. However, we decided to follow the definition of ´adolescent´ established by international organisations including the OMS and UNICEF. A significant number of papers were excluded considering our age range ( n  = 104). Defining adolescence as a period between 10 to 19 years old could be a limitation to our study. Thirdly, this review focused on common mental health problems such as depression, anxiety and emotional distress and excluded psychiatric conditions such as anorexia, schizophrenia and substance misuse, mainly due to the particular nature of the help-seeking processes. However, the exclusion of substance misuse problems could be seen as a limitation of this study due to its high prevalence in adolescence, making it a particularly sensitive issue during this period of life [ 136 ]. Finally, this review prioritised the overinclusion of studies to have an overall picture of the existing evidence regarding help-seeking for mental health problems in adolescents. As a result, low quality studies were included in the analysis and may affect the interpretation of the findings. There were some notable strengths in this review. This is the first systematic review studying help-seeking barriers, facilitators and interventions in order to give a comprehensive review of the topic. The search strategy developed was over-inclusive, using an optimal database combination, including multiple languages and PPI involvement in the development of the topic.

In conclusion, stigma and negative beliefs about mental health services appear as the most significant barriers to help-seeking for adolescents, whereas previous positive experiences with services and good mental health literacy are the most relevant facilitators. There are a number of interventions being developed to promote help-seeking for mental health problems in adolescents, and most of them take place in high education settings. They include a range of delivery methods including psychoeducation, stigma and depression awareness campaigns, online tools and peer training. Since such initiatives are relatively new, there is a need for more trials, with longer follow-up periods and the use of reliable and validated tools focused in future help-seeking behaviour. Despite school seeming to be the ideal setting for deploying these interventions, it is important to consider adolescents outside the school system who may be in more need of attention for psychosocial and mental health problems.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Abbreviations

Mixed Methods Appraisal Tool

Randomised Controlled Trial

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Acknowledgements

The completion of this systematic review would not have been possible without the support of The National Commission of Scientific and Technological Research (CONICYT-Beca Chile) under the Ministry of Education of the Chilean Government.

N/A. This review was conducted as a dissertation in the context of the MSc Clinical Mental Health Sciences at UCL.

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Antonia Aguirre Velasco

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The contributions of the authors are as follows: AA developed the review protocol, was the first screener and drafted the paper; IS was the second screener for this review; JB commented on the draft of the paper; MJ was the third contributor available to discuss any discrepancies between the two screeners; SR was the senior author, and was involved the design of the review questions, the protocol and commented on the draft of the paper. The author(s) read and approved the final manuscript.

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Aguirre Velasco, A., Cruz, I.S.S., Billings, J. et al. What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review. BMC Psychiatry 20 , 293 (2020). https://doi.org/10.1186/s12888-020-02659-0

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• Help-seeking
• Mental health
• Facilitators
• Interventions
• Systematic review

BMC Psychiatry

ISSN: 1471-244X

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Help-seeking: a review of the literature

• PMID: 727182
• DOI: 10.1007/BF00941418

Help-seeking encompasses a complex set of issues. The present survey appraises the empirical work covering three topics: the people who seek help, the role of the social network in the help-seeking process, and the outcome of the helping interaction. Included are reviews of where people turn for assistance, the type of problems for which they seek help, the kind of aid provided, and conditions influencing satisfaction with help received. Future research directions are presented with special emphasis on implications for effective delivery of services.

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• Research Support, U.S. Gov't, P.H.S.
• Adaptation, Psychological
• Community Mental Health Services*
• Decision Making
• Interpersonal Relations
• Life Change Events
• Referral and Consultation
• Stress, Psychological / therapy
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• Open access
• Published: 30 October 2023

Healthcare-seeking of medical students: the effect of socio-demographic factors, health behaviour and health status – a cross-sectional study in Hungary

• Afriza Umami 1 , 2 ,
• Viktória Zsiros 1 ,
• Ágnes Maróti-Nagy 1 ,
• Zsuzsanna Máté 1 ,
• Sudalhar Sudalhar 2 ,
• Regina Molnár 1   na1 &
• Edit Paulik 1   na1  

BMC Public Health volume  23 , Article number:  2126 ( 2023 ) Cite this article

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Medical students are more likely to have various physical and psychological issues, but less information is available about the healthcare-seeking behaviour for physical and mental health issues. The aim of this study is to determine the factors affecting medical students’ healthcare-seeking when visiting a general practitioner (GP) and/or psychologist.

688 medical students (326 International and 362 Hungarian,) participated in a cross-sectional study. The information was gathered using a self-administered online questionnaire and covered socio-demographic background, health behaviour, general and mental health status and healthcare-seeking. For analysing adjusted associations, multivariable logistic regression models were used.

Overall, 56.8% of medical students visit the GP; and 17.2%, the psychologist. Hungarian medical students visited the GP with chronic diseases, International medical students were more likely to visit a GP when they encountered sexual activity and had chronic diseases. Moreover, there was a significant correlation between sex, alcohol consumption, and perceived stress in the total sample of psychologist visits. When Hungarian medical students were in their clinical years and had a poor self-rated mental health, they were more likely to visit a psychologist. Whereas female international medical students and those who had poor self-rated mental health were more likely to seek psychological help.

Students visit a GP and/or psychologist is associated with a variety of factors, including socio-demographic background, health behaviours, and health issues. Medical schools should encourage help-seeking behaviours and early disclosure of medical students. Their ability to grasp healthcare attitudes and designing treatments will be important for both their academic success and future profession.

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The absence of seeking out physical or mental health care among medical students is acknowledged as an increasing prevalent issue by the literature [ 1 , 2 ]. Medical students are reluctant to seek out treatment, instead, they show preference to seek help from informal sources, such as friends and family [ 3 ]. Informal medical care from colleagues is an element of the culture of doctors and may be an example of what future doctors learn from their role models [ 3 , 4 ]. A high prevalence of mental health illnesses, lack of or delay in obtaining health care, self-diagnosis, self-prescribing and dangerous behaviours have all been observed among qualified doctors [ 5 ]. Medical students retrieve attitudes and values from professional role models, and they could also adopt behavioural traits that encourage them to get informal care for physical and mental health issues [ 4 ].

In a survey conducted at a British medical school, it has been discovered that 43% of the students had unofficially contacted a doctor who was a friend or family member, 9.2% had initiated their own investigations, and 25% had been examined by a colleague [ 6 ]. Additionally, 90% of the respondents in North American questionnaire-based research conducted in nine medical schools have reported a need for medical attention while in training. Two-thirds of them has received informal care from colleagues and half requested that a fellow student do a physical examination [ 7 ]. College students in China were found to be more reliant on seeking out online health information (OHI), just 32.4% followed up with doctors, and around 20% experienced internet hacking/fraud which will have a negative impact on their health in the future [ 8 ]. The study found that Chinese students rely on OHI to manage both their own and others’ health without sufficient knowledge/skills to identify misinformation [ 8 ].

The prevalence of mental distress among medical students ranged between 12.2 and 96.7% according to a systematic review that was conducted on 16 studies that were identified outside of North America in the English-speaking world [ 9 ]. According to a study conducted in Hungary [ 10 ], Hungarian students reported less mental well-being than students from the Mediterranean region, Israel, and Scandinavia. Furthermore, it was discovered that 49.7% of foreign students in Hungary who self-reported their mental health had poor mental health [ 11 ]. Meanwhile, the chronic disease burden is increasing globally. The study reported that 41.5% of medical students in Morocco confirmed having a chronic disease, among which 80% were under treatment [ 12 ]. Furthermore, research conducted among residents of various specialties in Saudi Arabia reported that chronic disease was reported by 29.1% [ 13 ].

Researchers should be aware of the physical and mental health issues for which students are likely to require assistance when analysing their behaviour of seeking health care [ 4 ]. Medical students seem to be more distressed than the population in general and more anxious than non-students of same ages [ 2 , 14 ]. Studying as well as having concerns about competency and achievement leads to the development of stress among medical students [ 15 ]. Nonetheless, there is little information available on the physical health of medical students, their behaviour when seeking assistance for physical and mental health issues, and how it is related to the accessibility of issues or other barriers to receiving different types of care [ 4 ]. Although the prevalence of physical illness among medical students remains uncertain, there is some evidence to suggest that they will have significant health concerns during their training [ 16 ].

The literature consistently recognized the high prevalence of mental distress among medical students [ 9 , 17 , 18 , 19 ] but physical health of medical students is less understood [ 4 , 20 ] however, one longitudinal study has found that the physical health can decline during medical school years [ 21 ]. Medical students often refrain from disclosing and seeking help [ 20 , 21 , 22 ], which could potentially endanger both themselves and their patients. There is a scarcity of literature on the factors influencing their choices regarding seeking help or disclosing health conditions [ 20 ]. Other studies tend to look at the role of the medical school in monitoring and improving student welfare that is mainly related to mental distress [ 23 ] and the importance of stress management programmes [ 24 ], rather than the role of general practitioners (GPs) in the support and management of physical and mental health. Hence, this study focusing to investigate the visiting the GP and/or the psychologist and the associated factors among medical students. Moreover, medical students experience a higher incidence of health issues compared to students in other fields [ 2 , 14 ]. This can be attributed to the significant risk factor associated with pursuing education at a medical university and subsequently working as a doctor [ 4 ]. It is widely recognized that doctors often face challenges related to their mental and physical well-being. Hence, it is crucial to examine their health-seeking behaviour, as improving this aspect will be vital for their future healthcare needs.

Study design and participants

A cross-sectional study was employed among medical students at the University of Szeged (USZ), Hungary. The study was carried out between April and October 2021. The medical students from the first to sixth years were invited to participate in the online survey using convenience sampling. The survey was completed by 688 students in total (n = 362 Hungarian and n = 326 international students). The participation was voluntary and anonymous.

The total number of medical students enrolled at the University of Szeged was 2,382 students (Hungarian students 1,233 and international students 1,145) in the 2020/2021/2 academic year. The sample size was taken by calculating the 95% confidence level, a margin of error (ε) of 5%, and 50% population proportion.

Medical treatment of the students at the University of Szeged

The medical services available to medical students are easily accessible and located in the city centre. There are general practitioners in primary care, where services are provided only through appointments with a GP through the modulo platform. Secondary care of all students (regardless of the type of insurance) is provided at the clinics of the Albert Szent-Györgyi Clinical Center. In each case students need to contact the institutions’ own reception desk first. If students need emergency assistance, they can come to emergency care or call the ambulance service.

In addition, there is a student counselling centre as well as a local psychologist. Medical and counselling services are available in Hungarian, English and also German, however staff available for English and German are limited. Hungarian and international (who receive scholarships from the Hungarian government) students have health insurance (social security number, SSN). If students do not have SSN they can use private insurance such as Generali stadium health insurance, which must be paid by the student. As long as students have health insurance, the psychological services they receive are also free.

Data collection and measurements

Online questionnaires were used to collect data. Students were requested to complete the questionnaire by clicking on the link given on the teaching platform before or after the teachers delivered the lecture or practice. The questionnaire took about 10–15 min to complete. The questionnaires were available in both English and Hungarian, and participants were required to fill in the informed consent before starting the online survey. Only fully completed questionnaires were taken into account. In our online questionnaire, respondents were required to answer all questions, as it was designed to prevent the submission of incomplete responses. This approach ensured that participants could only proceed with the survey after providing answers for all the questions.

Socio-demographic characteristics

Age: Students were asked to provide their age in years. For data analysis, age was divided into two categories: 18–25 and 26–37 years. Sex: Students were given the choice of choosing either a male or female sex on the questionnaire. Years of study: the years of study were categorized into ‘preclinical (1st/2nd)’ and ‘clinical (3rd/4th/5th/6th)’. Relationship status was dichotomized as ‘not in relationship (single/divorced/living separated)’ and ‘in relationship (married/common-law marriage/living together/ having a partner but not living together)’. The financial situation of the students’ family was evaluated by a 5-point Likert scale, which was dichotomized as ‘poor income’ (very bad/bad/average) and ‘high income (good/very good)’.

Health behaviours

Smoking and alcohol consumption: if they smoked or drank alcohol, the response options were Yes (yes, occasionally/yes, regularly) or No. Sexual intercourse: if the students ever had sexual activity during medical school, and the response options were Yes or No.

Health status

Chronic diseases: if medical students ever experienced any chronic illness during their study period, either self-determined or diagnosed by a doctor; response option was Yes or No. Body mass index (BMI), there were two categories, underweight and normal: BMI ≤ 24.9 kg/m 2 and overweight and obese: BMI ≥ 25.0 kg/m 2 . Self-rated general health and mental health reported by using a five-point Likert scale (1 = very bad, 5 = very good). The respondents had to answer the question regarding general health, “how do you evaluate your general health status?“ and for mental health they were asked, “how do you evaluate your mental health status?“. For the purposes of data analyses, self-rated health (SRH) was categorized as good (scores 4 and 5) and poor (scores 1 to 3).

Perceived stress scale (PSS): The 10-item Perceived Stress Scale (PSS-10) [ 25 ] is a 10-item questionnaire originally developed by Cohen et al. (1983). Respondents were asked how often they felt a certain way on a five-point scale from ‘never’ to ‘very often’. PSS is not a diagnostic instrument, and the developer has not published any score cut-offs [ 26 ]. In the current study, for the purposes of data analysis, PSS was categorized as lower stress (score < 14) and higher stress (score ≥ 14) categories refer to previous study [ 27 ].

• Healthcare-seeking

Healthcare-seeking behaviour is defined as any activity performed by those who assumed they had a health issue or became ill with the intention of discovering an appropriate treatment [ 28 ]. Researchers determined that visits to the GP and psychologist are forms of healthcare-seeking behaviours. Visiting a GP or a psychologist: students answered the question if they visited the family doctor in the previous year, if they visited a psychologist in the previous year, and the response options were Yes and No.

Statistical analysis

Data were analysed by IBM SPSS ‘Statistics 28.0’. Socio-demographic characteristics, health behaviours, health status and healthcare seeking were analysed using chi-square test. Univariable logistic regression analysis of these variables was performed to evaluate unadjusted relationships, only variables that have a p value < 0.05 were carried out by multivariable analysis. Multivariable logistic regression models were constructed to evaluate adjusted relationships, the adjusted variables were socio-demographic factors (age, sex, years of study, relationship status, and economic status). All analyses were carried out as a comparison of the Hungarian and international students. In the logistic regression analysis Nagelkerke R 2 values were used to evaluate the explanatory power of the models, whereas Hosmer and Lemeshow proposed a goodness-of-fit test.

The study protocol was reviewed and approved by the Human Institutional and Regional Biomedical Research Ethics Committee, University of Szeged, Hungary (license number: 4936). All participants were informed of the objectives and procedures of the study and their rights to withdraw from the study. Informed consent was obtained from all included participants. Anonymous data were collected and held securely.

Characteristics of the sample

The characteristics of the respondents are described in Table  1 . The majority (86.6%) of the students were aged 18–25 years with the mean age of 22.47 ± 2.75 years. There were significant differences between the Hungarian and the international medical students in socio-demographic factors, such as age, sex, year of study, relationship and economic status.

There was no significant difference in smoking behaviour between Hungarian (21.3%) and international students (23.9%) (p = 0.405), while alcohol consumption and sexual activity differed significantly between the two groups, p < 0.001 and p = 0.003, respectively. Hungarian (alcohol 77.9%; sexual intercourse 58.3%); International (alcohol 61.3%; sexual intercourse 46.9%).

There was no significant difference in self-rated health and chronic illnesses between the two groups. Meanwhile, more than a quarter (70.2%) of the international students reported having a BMI ≥ 25.0 kg/m 2 , whereas 84.0% of the Hungarian students had a BMI ≥ 25.0 kg/m 2 (a statistically significant difference; p < 0.001).

In the total sample, there was a difference in the proportion of visits to the GP (56.8%) and the psychologist (17.2%); the number of visits to the psychologist was lower. Concerning the number of visits to the GP between Hungarian (57.7%) and international (55.8%) students, there was no significant difference. On the other hand, there was a statistically significant difference between the two groups regarding visits to the psychologist: Hungarian (19.9%) and international (14.1%) (p = 0.045). This difference could potentially be attributed to the availability of psychological services, which might vary between the groups and influence the utilization of such services.

Medical students visit to the GP

In the univariable logistic regression (Table  2 ), there was no significant relationship identified between the socio-demographic characteristics and the GP visits by medical students in both groups.

Health behaviours significantly associated with visiting the GP were found to be alcohol consumption and sexual intercourse in the total sample. While smoking behaviour had no significant relationship in either group. General health status significantly associated with the GP visits included the presence of a chronic disease as well as BMI scale in the total sample. In contrast, self-rated general health had no significant association in either group.

International students were more likely to visit GP when they had chronic illness and experienced health behaviour (such as alcohol and sexual intercourse). Hungarian students were more likely to visit GP when they had chronic illness. In the total sample, alcohol, sexual intercourse, chronic illness and BMI associated with visiting GP among medical students.

According to the multivariable logistic regression (Table  3 ), only chronic diseases were significantly associated in the total sample. International medical students were more likely to visit a GP when they had experienced sexual intercourse (AOR = 1.86, 95%CI 1.14–3.01, p = 0.012) and had a chronic disease (AOR = 3.22, 95%CI 1.46–7.07, p = 0.004). On the other hand, Hungarian medical students were more likely to visit a GP when they had chronic disease (AOR = 3.70, 95%CI 1.93–7.09, p < 0.001).

Medical students visit to the psychologist

According to the univariable logistic regression analysis (Table  4 ), socio-demographic factors that have a significant relationship with visits to a psychologist was sex in both groups, but the year of study was relevant only in the Hungarian group. Health behaviours included alcohol consumption were significantly related to visits to the psychologists in the total sample. Moreover, mental health status, PSS and self-rated mental health had a significant relationship in all groups.

Table  4 indicates that among international students, a higher perception of stress and poor self-rated mental health were associated with a greater likelihood of visiting a psychologist. On the other hand, within the group of Hungarian students, visiting a GP was more probable when they were in clinical years, experienced higher levels of perceived stress, and reported poorer mental health.

With regard to the multivariable analysis (Table  5 ), there was a significant correlation between gender, alcohol consumption, and PSS in the total sample of the visits to the psychologists. Hungarian medical students were more likely to visit the psychologists when they were in the clinical years (AOR = 1.74, 95%CI 1.00-3.01, p = 0.048) and had poor self-rated mental health (AOR = 2.45, 95%CI 1.31–4.60, p = 0.005). While female international (AOR = 2.21, 95%CI 1.11–4.41, p = 0.024) students and those who had poor self-rated mental health were more likely to seek psychological help (AOR = 3.08, 95%CI 1.47–4.45, p = 0.003).

Main findings

The findings revealed that medical students’ utilization of medical assistance from GPs or psychologists remained low, aligning with similar observations made in other studies [ 1 , 4 ]. Medical students may feel they have the knowledge to overcome their health problems by seeking help from friends or family members [ 3 , 20 ]. The same opinion has been expressed in a study that students tend to avoid or delay disclosure, and they seek help because of the perceived risk to their future [ 6 , 16 ]. Meanwhile, in another study, it has been suggested that the reason for coming to professional healthcare was not because it would hinder the students’ studies or reduce their achievement because of the disease they were having [ 4 ], but they were reluctant to come to the GP for reasons of the type and level of the disease they were experiencing [ 20 , 29 ].

Our study showed that both Hungarian and international medical students who had chronic illnesses had the possibility to visit the GP. This finding was supported by a study which stated that students had symptoms of chronic diseases, such as respiratory, gastrointestinal, musculoskeletal symptoms or miscellaneous would come to visit the GP [ 29 ]. The same thing has also been described by previous studies which stated that health seeking behaviour among medical students might be influenced by the presence or absence of chronic diseases the students had [ 30 ]. However, another study claims that only students with symptoms of the disease at a severe stage would come to seek medical assistance [ 7 , 31 ]. When analysing between local and international students, there may be several things that need to be considered, as it is known in the previous research that the mental health of international students might be influenced by the process of acculturation that they experience [ 11 ].

Likewise, students who often engage in risky health behaviours would have an impact on their physical and mental health, so that these students need appropriate health assistance [ 32 ]. The current findings suggest that international medical students who were sexually active were more likely to visit a GP. Hobs reports in his research that family doctors are the most common providers of support (47.5–54.8%), less than half of the individuals experiencing unpleasant sexual difficulties sought help or advice to health professionals [ 33 ]. The primary obstacle to students seeking medical care (70.4%) and students in need of sexual health counselling (72.2%) was acceptance of services [ 34 ].

The findings of the current study show that students were less likely to come to the psychologist than to the GP. This is of particular concern even though 50.9% of the students reported experiencing poor mental health, they were reluctant to come for psychological help. This might be influenced by the stigmatization of students when they have poor mental health problems [ 20 , 35 ]. Worries about confidentiality were only seen as a barrier to seeking help for mental health problems [ 20 ] to consult friends and⁄ family informally about symptoms relating to mental health problems [ 4 ].

A prior study has revealed that men and women exhibit comparable help-seeking behaviours [ 36 ]. However, in the current study, it was observed that female students were more likely to seek the advice of a psychologist, and this finding was also present in the study of Mou, that is, women were more likely than men to take precautions [ 37 , 38 ]. The likelihood of contracting a disease, how well people respond to treatments, and how frequently they seek medical attention have all been found to be influenced by sex and social circumstances [ 39 ]. Another study has claimed that patients’ self-reports revealed gender variations in the way they sought medical attention with women saying they contacted their primary care physician more frequently than males for both physical and mental health issues [ 38 , 40 ].

The study conducted by Sawaha highlights that the academic year affects the search for health assistance [ 30 ] similarly to the findings in the current study where clinical students tried to seek help for psychological problems more often by consulting a psychologist. Students in higher academic years had a higher probability to be in the risk pattern of burnout, so they needed to come to the psychologist more often [ 24 ]. In addition, this study found a link between psychological visits and perceived stress, and prior research indicated that medical students generally experienced greater levels of perceived stress and emotional distress [ 24 ]. A more thorough understanding of how various sorts of stressors affect college students’ mental health will certainly allow any such efforts to more accurately identify and offer options to those who need support [ 41 ].

The recent findings argue that alcohol consumption was associated with seeking help from a psychologist. Consequently, drinking issues may have a very negative effect on mental health. One recent study showed that drinking alcohol were more likely to have mental health problems [ 23 ]. Excessive alcohol consumption and alcoholism can exacerbate pre-existing disorders like depression, or they may lead to the development of new issues, such as anxiety, depression or significant memory loss [ 14 , 42 ].

Strengths and limitations

In this study, health issues concerning both general health and mental health were discussed by using self-rated health assessments that are easy to assess by respondents and do not require much time in answering questionnaires. As another strength of the survey, a perceived stress scale that is easily understood by respondents in assessing the perception of stress was used. Nevertheless, despite the use of valid measurements and online survey measure, this study has several limitations. First, the cross-sectional study design may cause result bias. Second, convenience sampling was employed to recruit medical students’ participation, which may affect the representativeness of our findings. Third, since the data collection was conducted during the COVID-19 pandemic in Hungary, it may have an impact on health status (including mental health) and healthcare-seeking behaviours of students. Fourth, data on the students’ country of origin and the use of secondary care were not available or were not analysed in this study.

Future studies should consider using longitudinal study design, mixed method (qualitative and quantitative), dig deeper into the reasons why students seek medical assistance other than the variables in this study. The reasons why students visit psychology less frequently than to the GP can be explored by in-depth interviews. Future researchers can explore the barriers to seeking help among medical students.

Healthcare-seeking was influenced by socio-demographic characteristics, health behaviour and health issues among medical students. This finding is encouraging medical schools to promote students to ask for assistance and come forward with problems early as well as increase student awareness in order to reduce risky behaviours. Therefore, in addition to their patients, a medical student’s future career depends on the ability to fully comprehend healthcare attitudes and to develop solutions that will improve health behaviour and to get appropriate health care.

Data Availability

The datasets used during the current study are available from the corresponding author on reasonable request.

Abbreviations

• General practitioner

Online health information

University of Szeged

Self-rated health

Perceived stress scale

Body mass index

Confidence Interval

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Acknowledgements

We are grateful for the contribution of all those students who participated in this study.

The research project had no funding from any organizations. The manuscript publication was funded by University of Szeged Open Access Fund (grant number: 6026) This funding enables open access publication but has no role/influence on study design, data collection, analysis, interpretation and manuscript writing.

Open access funding provided by University of Szeged.

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Regina Molnár and Edit Paulik contributed equally to this work and share last authorship.

Authors and Affiliations

Department of Public Health, Albert Szent-Györgyi Medical School, University of Szeged, Dóm tér 10, Szeged, H-6720, Hungary

Afriza Umami, Viktória Zsiros, Ágnes Maróti-Nagy, Zsuzsanna Máté, Regina Molnár & Edit Paulik

Stikes Muhammadiyah Bojonegoro, Bojonegoro, Indonesia

Afriza Umami & Sudalhar Sudalhar

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AU, EP, RM: methodology, formal analysis, writing original draft, interpretation and revise. EP, RM: reviewing and supervision. AU, VZ, AMN, SS, ZM: investigation, conceptualization, interpretation, revise, and editing. All authors have read and approved the final manuscript.

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Correspondence to Afriza Umami .

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Umami, A., Zsiros, V., Maróti-Nagy, Á. et al. Healthcare-seeking of medical students: the effect of socio-demographic factors, health behaviour and health status – a cross-sectional study in Hungary. BMC Public Health 23 , 2126 (2023). https://doi.org/10.1186/s12889-023-17041-4

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Research Article

Factors associated with help-seeking behaviour among individuals with major depression: A systematic review

* E-mail: [email protected]

Affiliation Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

Affiliations Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany, Department of Health Services Research, Carl von Ossietzky University, Oldenburg, Germany

• Julia Luise Magaard, 
• Tharanya Seeralan, 
• Holger Schulz, 
• Anna Levke Brütt

• Published: May 11, 2017
• https://doi.org/10.1371/journal.pone.0176730
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Psychological models can help to understand why many people suffering from major depression do not seek help. Using the ‘Behavioral Model of Health Services Use’, this study systematically reviewed the literature on the characteristics associated with help-seeking behaviour in adults with major depression. Articles were identified by systematically searching the MEDLINE, EMBASE and PsycInfo databases and relevant reference lists. Observational studies investigating the associations between individual or contextual characteristics and professional help-seeking behaviour for emotional problems in adults formally diagnosed with major depression were included. The quality of the included studies was assessed, and factors associated with help-seeking behaviour were qualitatively synthesized. In total, 40 studies based on 26 datasets were included. Several studies investigated predisposing (age (N = 17), gender (N = 16), ethnicity (N = 9), education (N = 11), marital status (N = 12)), enabling (income (N = 12)), need (severity (N = 14), duration (N = 9), number of depressive episodes (N = 6), psychiatric comorbidity (N = 10)) and contextual factors (area (N = 8)). Socio-demographic and need factors appeared to influence help-seeking behaviour. Although existing studies provide insight into the characteristics associated with help seeking for major depression, cohort studies and research on beliefs about, barriers to and perceived need for treatment are lacking. Based on this review, interventions to increase help-seeking behaviour can be designed.

Citation: Magaard JL, Seeralan T, Schulz H, Brütt AL (2017) Factors associated with help-seeking behaviour among individuals with major depression: A systematic review. PLoS ONE 12(5): e0176730. https://doi.org/10.1371/journal.pone.0176730

Editor: Ali Montazeri, Iranian Institute for Health Sciences Research, ISLAMIC REPUBLIC OF IRAN

Received: November 23, 2016; Accepted: April 14, 2017; Published: May 11, 2017

Copyright: © 2017 Magaard et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This study was not funded and part of the dissertation of Julia Luise Magaard (JLM). However, JLM, Anna Levke Brütt (ALB) and Tharanya Seeralan (TS) received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression (DFG BR4859/3-1). The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper.

Competing interests: The authors declare that they have no competing interests.

Introduction

Major depression is a common mental disorder and one of the leading causes of health impairment worldwide [ 1 ], resulting in serious impairment of functioning and decreased quality of life [ 2 , 3 ]. To treat major depression depending on severity, American and European guidelines (e.g. [ 4 , 5 ]) recommend treatment options as psychotherapy, pharmacotherapy, or a combination of both. Despite the availability of effective treatment options, researchers continue to find that a significant number of individuals suffering from major depression do not seek professional help. Using studies on service utilization rates for major depression in community-based surveys, Kohn, Saxena [ 6 ] reported that the percentage difference between number of people needing treatment for major depression and number of people seeking professional help ranged between 15.9% (12 month, Florence) [ 7 , 8 ] and 83.9% (current, UK) [ 9 ]. They estimated that the median untreated rate for depression is 56.3% worldwide [ 6 ].

Various psychological models have been used to explain variations in help-seeking behaviour among populations, such as the Self-Regulation Model [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ]. From the sociological perspective models like the Pescosolido’s Network Episode Model [ 13 ], Kadushin’s theory about why people go to psychiatrists [ 14 ] and the Behavioral Model of Health Services Use [ 15 ] were specifically constructed to explain help-seeking behaviour. The ‘Behavioral Model of Health Services Use’ suggests that people’s predisposition to use services, factors which enable or impede the use of services and people’s need of care predict and explain health behaviours like use of health services [ 15 ]. According to the model, all health behaviours influence health related outcomes. The model includes feedback loops to demonstrate that outcomes can affect health behaviours, predisposing, enabling and need factors and health behaviours can influence predisposing, enabling and need factors. In the current version of his ‘Behavioral Model of Health Services Use’, Andersen [ 15 ] distinguishes between contextual and individual characteristics influencing service utilization and health-related outcomes ( Fig 1 ). The model asserts that contextual and individual characteristics consist of predisposing, enabling and need factors [ 15 ]. Individual characteristics are measured at the individual level, whereas contextual characteristics are measured at an aggregate level (e.g., families, communities, national health care system). Contextual characteristics include health organizations and provider-related factors as well as community characteristics [ 15 ]. At the individual level, a person’s beliefs (e.g., attitudes towards health services), demographic characteristics (e.g., age) and social factors (e.g., education) define his or her predisposition to use health services. Additionally, the availability of financial resources to pay for services as well as organizational factors (e.g., regular source of care, means of transportation to care) enable or impede the use of health services at the individual level. In the “Behavioral Model of Health Service Use” it is not clearly defined if social relationships and social support are considered as predisposing or enabling factors. We agree with Andersen’s argumentation that social support can facilitate or impede help-seeking behaviour and therefore serves as an enabling resource [ 15 ] whereas the social structure including family situation predisposes help-seeking. Furthermore, perceived and evaluated need influences help-seeking behaviour. Professional judgement about people’s health and need for treatment is represented by evaluated need whereas perceived need includes people’s perspective on their own health [ 15 ]. The model has frequently used in studies and systematic reviews (e.g. [ 16 , 17 , 18 ]). According to validity, associations between different individual characteristics and services use were found empirically. However, causal conclusions cannot be drawn from analyses on the basis of mainly cross-sectional data (e.g. [ 16 ]). Individual characteristics of the current model can be expanded to include predictors of help-seeking behaviour like treatment and illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ].

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https://doi.org/10.1371/journal.pone.0176730.g001

The current review focusses on contextual and individual characteristics as well as use of personal health services and relations between characteristics and use of personal health services (printed in bold).

In recent years, several quantitative studies have used Andersen’s model to investigate the factors influencing professional help-seeking behaviour among individuals suffering from depression (e.g. [ 17 , 18 ]). Additional quantitative studies on this subject have been conducted without referral to Andersen’s model (e.g. [ 19 ]). However, a systematic review of these findings has not been performed. The only existing review [ 20 ] was published 14 years ago and focused on studies using heterogeneous definitions of depression or depressive symptoms and help-seeking behaviour, finding that the help-seeking behaviour of individuals with depression or depressive symptoms was influenced by age, ethnicity, social support and clinical and psychiatric factors. Further studies focussed on specific populations [ 21 ] or specific factors associated to help-seeking [ 22 , 23 ]. Recently, a qualitative synthesis of interview studies about help-seeking behaviour among people with depression was published [ 24 ].

The purpose of this review was to apply a theoretical framework to investigate the individual and contextual characteristics associated with professional help-seeking behaviour for emotional problems in adults with major depression. Therefore, the current review addresses two questions: (1) Which characteristics associated with help-seeking behaviour in adults suffering from major depression are investigated in the literature? (2) How are these characteristics related to help-seeking behaviour in adults suffering from major depression?

In addition to including new literature, this review expands upon previous reviews in two ways: first, it embeds the findings within the ‘Behavioral Model of Health Services Use’ framework and integrates aspects of different models. By systematically reviewing observational studies using standardized diagnostic instruments to assess major depression, this review aims to synthesize the results of studies assessing help-seeking behaviour in a homogeneous population.

To the extent that they were applicable to observational studies and to the qualitative synthesis of results, the methods and results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 25 ] ( S1 Appendix ) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement [ 26 ]. No review protocol exists.

Search strategy

Two researchers (JLM, ALB) searched the MEDLINE, EMBASE and PsycInfo electronic databases in February 2017 (09.02.2017) using key words and a standardized vocabulary (e.g., MeSH) presented in S2 Appendix . These terms aimed to represent the concepts of ‘Depression’ and ‘Help-Seeking’. The search was restricted to ‘human’ and ‘English or German’. Additionally, the EMBASE search was restricted to ‘article’, and the search in PsycInfo to ‘all journals’.

Study selection

After excluding double hits, the title and abstracts of all articles (published in English or German) identified through the electronic search were screened to exclude clearly irrelevant articles. Two researchers (TS, JLM) independently screened the title and abstracts of 150 records. If at least moderate agreement was achieved (Kappa ≥ .41) [ 27 ], the remaining records were screened by JLM. Additionally, the reference lists of the relevant studies and reviews identified in the electronic search were manually examined.

In the second step, the full texts of all potentially relevant studies were independently reviewed by two researchers (TS, JLM). The decision to include studies was based on a priori defined inclusion criteria (IC) ( S3 Appendix ).

Study design

To identify the factors associated with help-seeking behaviour, we relied on observational quantitative studies because randomization of these influencing factors is not possible. Therefore, cohort, case-control and cross-sectional studies were included (IC 1), but intervention studies were excluded unless they retrospectively assessed help-seeking behaviour at baseline.

To investigate the factors of interest in a population with a comparable depression status, studies reporting on the help-seeking behaviour of individuals with a major depressive episode or major depression disorder were included (IC 2). To ensure the validity of the diagnoses, a sample or subsample with formally diagnosed major depression disorder or a major depression episode according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Statistical Classification of Diseases (ICD) or Research Diagnostic Criteria (RDC) was required (IC 3). We included studies investigating adult populations (IC 4) with depressive subsamples of population-based datasets to ensure that the samples included individuals not seeking care (IC 5).

Based on the guidelines and in accordance with other reviews on help-seeking [ 16 , 23 , 28 ], we defined professional help-seeking as contacting a health practitioner or service for mental health reasons at least once or receiving therapy including primary care and specialized care in outpatient and inpatient settings in a defined time period (IC 6). To ensure the homogeneity of our outcome, we decided to exclude studies assessing lifetime help seeking. Studies had to include results on the factors influencing help-seeking behaviour (IC 7).

We included studies if they fulfilled all of the inclusion criteria. If there were disagreements about the in- or exclusion of a study, the decision was discussed until consensus was reached (JLM, TS, ALB).

Data extraction and synthesis

The study characteristics, factors associated with help seeking, results and methodological quality were extracted by JLM and TS. Qualitative data synthesis was performed to illustrate which influencing factors were investigated and to discuss heterogeneous findings (e.g., adjusted and unadjusted results) from samples in heterogeneous contexts (e.g., countries, health care systems). Therefore, JLM and TS classified all investigated variables into individual and contextual predisposing, enabling and need factors according to the ‘Behavioral Model of Health Service Use’ [ 15 ]. Data synthesis was performed by vote counting because of the heterogeneity of settings, measures, adjustments and the number of investigated variables. Therefore, measures (e.g., odds ratios, chi-square, and regression coefficients) of the association between each variable and help seeking were grouped into significant positive, significant negative and non-significant results and were listed for each variable. Any disagreements between JLM and TS were discussed until agreement was reached. We documented if and which potential confounding variables were adjusted for in the analyses.

Assessment of methodological quality

Two researchers (JLM, TS) evaluated the methodological quality of all of the included studies. Because of the high level of homogeneity in study design, we considered only criteria with variance between studies. Consequently, three criteria were used ( S4 Appendix ). Two criteria of 14 from the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [ 29 ] were selected to examine internal validity (Q1 and Q2, S4 Appendix ). We added one criterion about the recruitment of a cohort from the Critical Appraisal Skills Programme [ 30 ] to focus on external validity (Q3, S4 Appendix ). A score of 1 was awarded for each criterion adequately fulfilled, with a potential score ranging from 0 (poor) to 3 (excellent). No studies were excluded because of poor quality rating.

Study characteristics

Altogether, 40 studies based on 26 datasets were included in the systematic review (see Fig 2 for an overview of the search process). The study characteristics are summarized in S5 Appendix . The 26 included datasets comprised 24 cross-sectional studies, one case-control study [ 31 ] and one cohort study [ 32 ]. The years of publication for these studies ranged from 1987 [ 33 ] to 2016 [ 34 ]. In 24 of the 26 datasets, the help-seeking behaviour of individuals with major depression was assessed in population-based samples within a certain region or country. The exceptions included a study investigating white-collar professionals from a specific corporation [ 35 ] and a study investigating the relatives and spouses of people seeking treatment for mental disorders and matched controls [ 31 ]. Most datasets were collected in the US (N = 10) and Canada (N = 8). The other datasets were collected in Finland (N = 3), Ethiopia (N = 1), Mexico (N = 1), Estonia (N = 1), Netherlands (N = 1) and Europe (N = 1). The sample sizes ranged between 102 and 18,927 participants with major depression [ 36 ].

https://doi.org/10.1371/journal.pone.0176730.g002

Quality of studies

The study quality was rated as ‘good’ (60%) for more than half of the studies, ‘excellent’ for one study [ 32 ], ‘fair’ for 35% of the studies, and ‘poor’ for one study [ 35 ]. S5 Appendix displays the ratings of methodological quality.

Individual predisposing factors

Thirty-nine studies and all 26 datasets reported results on individual characteristics, as shown in S6 Appendix .

Five studies assessed stigma and help-seeking beliefs; feeling comfortable with seeking help [ 37 , 38 ] and having the intention to seek help [ 38 ] were positively associated with help-seeking behaviour. Negative attitudes towards antidepressants were negatively related to help-seeking behaviour [ 39 ]. Lin and Parikh [ 38 ] reported no significant associations between help seeking and beliefs about improving through or without professional care and feeling embarrassed about seeking help. This finding is inconsistent with Diala, Muntaner [ 37 ], who found that participants who said they would be embarrassed if their friends knew they were getting mental health care were less likely to use it than others. Aromaa, Tolvanen [ 39 ] found no association between help-seeking behaviour and prejudices against mentally ill people. However, they found that a stronger desire for social distance was negatively related to help seeking. Boerema, Kleiboer [ 34 ] reported that own negative attitudes towards people with depression are negatively related to help-seeking, whereas participants’ beliefs about how other people think about depression was unrelated to help-seeking.

Kleinberg, Aluoja [ 19 ] found that a higher external locus of control was associated with increased help seeking.

Demographic factors

The associations between gender and help seeking were analysed in 16 datasets. In three US samples [ 18 , 32 , 40 ] and one Finish sample [ 39 ], being female was positively related to help-seeking behaviour. Sussman, Robins [ 33 ] reported the same association only among white Americans, not among black Americans. An association between gender and help-seeking was not found in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 40 , 43 – 45 ], American [ 31 , 35 ], Finnish [ 46 , 47 ], Netherlands [ 34 ] or Mexican [ 48 ] samples.

The association between age and help seeking was analysed in 17 different datasets and was mainly computed comparing different age groups. In eight datasets, age was significantly associated with help-seeking behaviour. Two of these studies reported a positive association between age in years and help seeking [ 31 , 39 ]. In the other five datasets, being middle-aged was significantly related to higher help-seeking rates [ 32 , 41 , 49 – 51 ].

Social factors

The associations between help-seeking behaviour and social factors are shown in S6 Appendix . Results were available for educational status (N = 11 datasets), ethnicity (N = 9 datasets), family and living situation (N = 15 datasets) and employment (N = 4 datasets)

The associations between help seeking and education in individuals with major depression were significantly positive or non-significant in the eleven datasets. For example, in three datasets, more years of education and a higher degree were positively associated with help-seeking behaviour after adjusting for clinical and socio-demographic variables [ 32 , 42 , 44 , 52 ]. After adjusting for clinical and socio-demographic variables, this positive association remained significant only in the Canadian dataset [ 40 ] and the US dataset [ 53 ].

Differences between help seeking by ethnic group were assessed in four Canadian and five US datasets. Belonging to a different ethnic group was defined differently between the studies. Differences in help-seeking between different ethnic groups were reported in seven studies [ 18 , 32 , 33 , 37 , 40 , 54 , 55 ]. For example, black Americans [ 55 ], African Americans [ 18 , 37 ], Mexican Americans [ 18 ], and ethnic minorities [ 40 ] had lower rates of seeking help compared to whites. No differences were reported between the help-seeking behaviours of people born in Canada and of Canadian migrants [ 44 ], except that lower rates of help-seeking were observed in a group of Chinese immigrants compared to a group of Canadians born in Canada [ 52 , 54 ]. The results from the ‘National Survey of American Life’ (NSAL) showed that although African Americans reported higher rates of seeking help than Caribbean Blacks, this difference was only significant in a sample of adults with severe or very severe symptoms [ 56 ] and was not significant in a sample of adults with mild to moderate symptoms [ 56 ] or in a subsample of mothers [ 57 ]. Sussman, Robins [ 33 ] reported that blacks had lower odds of seeking help than whites only in people with less severe depression.

Eight [ 33 , 34 , 38 , 40 – 42 , 44 , 52 ] out of 15 datasets found no association between help-seeking behaviour and marital status or living as married. In addition, no significant associations were reported for cohabitation [ 19 , 47 ], household size [ 19 ] or pregnancy [ 58 ]. However, four studies showed that being married or living as married was negatively associated with help-seeking behaviour [ 17 , 31 , 35 , 59 ]; in contrast, Chartrand, Robinson [ 32 ] found the opposite relationship. Gadalla [ 52 ] reported that single mothers with adult children had the lowest odds of seeking treatment in comparison to other women.

Individual enabling characteristics

Financial aspects were addressed in ten datasets, focusing mainly on income or household wealth. In Spanish respondents from the ‘European Study of the Epidemiology of Mental Disorders’ (ESEMeD), the low to average income group was negatively related to help seeking compared to the highest income group [ 41 ]. Diala, Muntaner [ 37 ] found a similar association in respondents from the ‘National Comorbidity Survey’ (NCS). Conflicting results were found in male respondents from the CCHS 1.2, in which help-seeking was positively related to a lower adjusted household income [ 17 ]. All other studies reported non-significant results regarding this association [ 18 , 31 , 32 , 38 , 40 , 42 , 44 , 52 , 53 ]. In the ‘Collaborative Psychiatric Epidemiology Survey’ (CPES), health insurance coverage doubled the odds of any use of depression therapy in the past year [ 18 ], while in the American samples in the ‘Joint Canada/United States Survey on Health’, this association lost significance in the multivariate model [ 40 ].

Regarding the influence of organizational factors on help-seeking behaviour, findings on the availability, accessibility and acceptability of care were available from the CCHS 1.2 [ 17 ]. Additionally, findings on the influence of having a regular medical doctor were available in the ‘Joint Canada/United States Survey on Health’ [ 40 ]. Availability, including waiting times and help not available in the area, was positively related to help-seeking among female Canadian respondents, whereas accessibility and acceptability were not related to help-seeking [ 17 ].

Social support was addressed in three datasets. In the CCHS 1.2, social support and help seeking were positively related in women only [ 17 , 52 ]. Although social support was not directly associated with help-seeking behaviour in the Estonian health survey, emotional loneliness was associated with increased help seeking among depressed persons with an external locus of control [ 19 ]. Dew, Bromet [ 35 ] found that receiving social support during the index episode was negatively related to help seeking, whereas receiving recommendations from others to seek professional help was positively related to help seeking.

Individual need characteristics

Studies on the need factors influencing help-seeking behaviour often focused on the severity of depression (14 datasets), psychiatric comorbidity (11 datasets), duration of episode (9 datasets), subjective disability (5 datasets), number of depressive episodes (6 datasets), somatic comorbidity (6 datasets), and presence of certain depressive symptoms (7 datasets) ( S6 Appendix ). Illness and symptom based need factors were assessed through structured interviews or questionnaires and were defined as professional judgements about people’s mental health status and therefore can be allocated to evaluated need, according to the “Behavioral Model of Health Services Use” [ 15 ]. Specifically, severity of depression was positively related to help-seeking in seven of the 16 datasets [ 31 , 39 , 40 , 46 , 47 , 60 , 61 ]. In addition, a longer duration of illness was positively related to help-seeking behaviour in six datasets [ 31 , 34 , 35 , 40 , 46 ] and was non-significantly related in three datasets [ 33 , 38 , 53 ]. After adjusting for socio-demographic and clinical variables, having more than one major depressive episode was no longer significantly associated with help seeking in the ‘Ontario Health Study’ (OHS) [ 38 , 53 ]. Furthermore, in three other datasets, no significant association occurred [ 31 , 35 , 53 ]. However, in the group of black US participants [ 33 ] and female Canadians [ 52 ], there was a significant positive association. Having trouble concentrating [ 31 , 35 , 46 ] and suicidal thoughts or ideation [ 31 , 35 , 46 , 52 ] were positively related to help-seeking behaviour. Conversely, three studies found no significant results for the latter association [ 32 , 38 , 53 ].

Psychiatric comorbidity was assessed in eleven datasets, and somatic comorbidity in seven ( S6 Appendix ). Having comorbid generalized anxiety disorder [ 17 , 44 , 47 ] or a panic disorder [ 31 , 62 ] was positively related to help-seeking behaviour. Interestingly, after adjusting for several clinical and socio-demographic factors, having a generalized anxiety disorder, agoraphobia or panic disorder in the previous 12 months was significantly related to higher help-seeking rates in OHS respondents but not in NCS respondents [ 53 ]. In contrast with the findings from the Ontario study, Lin and Parikh [ 38 ] found no significant differences analysing the same dataset. Moreover, comorbid phobic disorders were not related to help-seeking behaviour [ 31 ].

Chen, Crum [ 36 ] showed that people suffering from major depression and substance dependence were more likely to seek help than people suffering from major depression only. Other findings indicate no significant difference in help-seeking behaviour with comorbid substance dependence disorder [ 17 , 38 , 44 , 63 ] or alcohol or drug abuse [ 31 ]. Having any additional mental disorder was positively related to help-seeking behaviour in one [ 41 ] of four relevant studies [ 38 , 44 , 64 ].

Suffering from chronic somatic disorders was significantly associated with higher help-seeking rates in two datasets [ 17 , 44 , 52 , 65 ]. However, in five datasets, this association was non-significant [ 34 , 38 , 40 , 41 , 60 ]. Demyttenaere, Bonnewyn [ 65 ] found that people with depression who had comorbid painful physical symptoms had lower rates of help seeking than those without these comorbid symptoms. In older people from the same dataset, this association was not significant [ 66 ].

Contextual characteristics

Studies on the contextual characteristics of help seeking in individuals with major depression have focused on region or different countries. Living in an urban or rural area was not related to help-seeking behaviour in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 44 ] or American [ 32 ] samples. Additionally, no differences in help-seeking behaviour were found between the American and Canadian samples [ 40 ] or between the Francophone Canadian and European samples [ 67 ]. Differences in individuals’ help-seeking behaviour between different regions of the US were found in one [ 32 ] of two studies [ 31 ].

This paper aimed to systematically review the individual and contextual characteristics associated with professional help-seeking behaviour in adults suffering from major depression based on the ‘Behavioral Model of Health Service Use’. Several studies investigated the association between help-seeking behaviour and individual characteristics, such as socio-demographic predisposing factors (e.g., age, gender, ethnicity, education, and family status), enabling factors (financial situation/income) and need factors (e.g., severity of depression, comorbidity, and duration and number of episodes). Some studies focused on beliefs (n = 4) (predisposing factors), social support (n = 4), organization (n = 3) (enabling factors), and context (n = 8) (e.g., urban vs. rural, country) and help-seeking behaviour. No study focusing on need for mental health treatment was included. Similarly, studies investigating help-seeking behaviour for different diseases based on the ‘Behavioral Model of Health Services Use’ examined characteristics similar to those of the studies included in our review [ 16 ].

Based on the current review, it appears that several factors may influence the likelihood that an individual suffering from major depression will seek professional help.

Predisposing factors that seem most likely to decrease help-seeking behaviour in individuals with major depression are, being young or elderly, being male, belonging to certain ethnic groups and having a lower educational status. Although these groups may be at a higher risk for not seeking professional help for major depression, the reasons for this higher risk need to be clarified. Certain structural or attitude-related barriers to seeking care among individuals in these groups may explain the findings. For instance, synthesizing qualitative studies, Doblyte and Jiménez-Mejías [ 24 ] identified attitudinal barriers for help seeking among depressed man, ethnic minorities and young adults: They concluded that help seeking is a threat to hegemonic masculinity, that the fear of disclosure and being judged was strongest among young adults and that ethnic minorities were more willing to keep depression within family [ 24 ]. Apart from attitudinal barriers, structural barrier like cultural inappropriateness of interventions could explain lower help-seeking rates among ethnic minorities [ 24 ].

The majority of studies reported no association between income and help-seeking behaviour. A possible explanation for this finding might be that income as an indicator is not sensitive enough to detect socioeconomic differences in the use of health care services [ 68 ]. Regardless, accounting for the financing of health care systems it is necessary to interpret these associations [ 15 ].

There is some evidence that the severity of depression, longer and more depressive episodes and the presence of anxiety disorders are related to higher help-seeking rates. These findings are consistent with those on help-seeking behaviour in individuals with depressive symptoms or depressive disorder [ 20 ]. However, as these findings were mainly based on retrospective cross-sectional studies, it remains unclear whether individuals affected by more severe depression are more likely to seek help. It is possible that individuals receiving treatment perceive their condition to be more severe than individuals without treatment. Qualitative findings indicate that the first hypothesis is more likely, because professional help-seeking is seen as the “final step”, because it “damages one’s self-definition” [ 24 ].

Based on the reviewed literature, the effects of additional individual predisposing factors such as attitudes on help-seeking behaviour and enabling factors like social support remain unclear. These psychosocial variables are mentioned in the ‘Behavioral Model of Health Service Use’, but which factors influence help-seeking behaviour in what way is not specified. Nonetheless, the initial findings show that social support might be associated with help-seeking behaviour [ 17 , 35 , 52 ]. Therefore, it might be worth distinguishing between informational social support (e.g., recommending seeking care) and emotional social support and investigating the interactions with other psychological concepts such as locus of control. Although the former could facilitate help seeking (e.g. [ 35 ]), the latter may only be associated with help seeking in certain populations (e.g., in individuals with an external locus of control [e. g. 19]). Regarding the influence of beliefs, feeling comfortable seeking care [ 37 , 38 ] was positively associated with help-seeking, whereas having negative beliefs about antidepressants and having a stronger desire for social distance from people who are mentally ill [ 39 ] and having negative attitudes towards them [ 34 ] might have a negative impact on help-seeking behaviour. Within the ‘Health Beliefs Model’ [ 11 ], these beliefs could be considered the perceived benefits and barriers to taking action. Henshaw and Freedman‐Doan [ 69 ] conceptualised help-seeking for mental illnesses using this model and examined the role of fears about treatment and stigma as psychological barriers. The desire for social distance from mentally ill people is known to be an indirect measure of stigmatizing beliefs towards people belonging to this group, and a dissonance between these negative stereotypes and the preferred self can impede help-seeking for mental health problems [ 23 ]. Fears about antidepressant treatment could be a particular problem if practical or psychological barriers to seeking psychotherapy exist.

As evidenced by the findings presented in the results section, several factors of the ‘Behavioral Model of Health Service Use’ seem to be not validated through the systematic review. For instance, mainly no associations between certain predisposing factors (e.g. employment status), enabling factors (e.g. income, organisation), need factors (e.g. somatic symptoms, general health) and help-seeking were identified.

Practical implications

The studies included in this review revealed that men, young and elderly adults, and people of certain ethnicities as well as individuals with a lower educational status with major depression are at risk of not seeking help, and these populations could be addressed in individually tailored interventions to increase help-seeking. In a review of randomized controlled trials, the majority of help-seeking interventions for depression, anxiety and psychological distress targeted young people [ 28 ]. In that review, Gulliver, Griffiths [ 28 ] provided some evidence that mental health literacy interventions (e.g., delivering destigmatisation information and/or providing information about help-seeking sources) can be effective in improving help-seeking attitudes. Mental health literacy is defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [ 70 ]. However, this positive association could not confirmed for help-seeking behaviour for these interventions [ 28 ]. According to Doblyte and Jiménez-Mejías [ 24 ] who stressed out the role of hegemonic masculine identity and its influence in limiting men’s help seeking behaviour, educational campaigns for primary care providers can facilitate communication between male patients and GPs. Additionally a slighter entrance into care can be achieved. In this spirit, trainings which increase GPs intercultural competence and awareness of cultural differences regarding e.g. illness definition should also be considered [ 24 ]. However, further research on interventions that increase help-seeking intentions and behaviour among individuals suffering from major depression is needed.

Limitations

The results of this review should be considered in light of several limitations. First, the vast majority of the studies reviewed were conducted in the US and Canada, which reduces the external validity of the findings. Second, the synthesis of results was limited because of the heterogeneity of the studies. Although the samples were homogenous regarding the formal diagnosis of major depression, the studies differed in terms of the samples’ age, gender and ethnicity as well as the health care systems affecting the participants. According to the ‘Behavioral Model of Health Service Use’, these contextual characteristics directly influence service utilization and indirectly influence service utilization through individual characteristics [ 15 ]. In addition, the results included different levels of adjustment. Third, reliable conclusions concerning whether a factor causes help-seeking behaviour were not possible, because the large majority of the studies used cross-sectional designs and retrospective data. Fourth, there was a lack of studies that quantitatively investigated the influence of individuals’ beliefs and perceptions on their help-seeking behaviour. Finally, because of the heterogeneous measures and adjustment methods used, a quantitative synthesis was not appropriate.

Plea for consideration of the subjective perspective in help-seeking behaviour

The focus on socio-demographic and clinical variables in the reviewed literature is understandable, as the majority of the studies utilized secondary datasets, thus limiting the variables available for analysis. Nevertheless, it is important to obtain information on the subjective perspective to better understand the complex process of help seeking. Furthermore, including this perspective could provide insight into the associations between certain socio-demographic variables and help seeking. For instance, several studies have already been conducted to shed light on depressed men’s lower help-seeking rates (for review see [ 21 ]) and on men’s delays in medical and psychological help-seeking (for review see [ 71 ]). Specifically, embarrassment, distress or anxiety related to using health care services, need for emotional control, the perception of symptoms as minor and poor communication with health professionals were identified as barriers for help-seeking among men [ 71 ]. Although the ‘Behavioral Model of Health Service Use’ [ 15 ] does not focus on this subjective perspective, it is explicitly included in the predisposing contextual individual beliefs and implicitly included in perceived need . Psychological models such as the Self-Regulation Model of Illness Behavior [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ] focus on the individual’s perspective in the help-seeking process. According to these models, illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ] influence help-seeking behaviour. For instance, a qualitative analysis using the Self-Regulation Model found that primary care patients with depression who did not seek treatment believed that the treatment would not be effective, that depression would be short-lived and that it would not affect their daily lives [ 72 ]. Accordingly, it is promising to focus on psychological variables that affect the decision-making process of seeking help to better predict behaviour.

Future directions for research

We suggest that future quantitative research on help-seeking behaviour among individuals suffering from major depression should focus more on the individuals’ perspective and include psychological theories as a framework for understanding the help-seeking process. Additionally, the influence of illness beliefs, treatment beliefs, anticipated stigmatization and perceived need for mental health care on help seeking may be worth investigating. Future research should provide insight into the associations between predisposing, enabling and need factors to improve the understanding of the complex process of help seeking. Therefore, the characteristics identified in the literature should be further considered.

Future prospective cohort studies on the causal relations between predisposing, enabling and need factors and help-seeking behaviour among individuals suffering from major depression should also be conducted. Measuring predisposing beliefs, perceived barriers, clinical variables, and perceived need prior to assessing help-seeking behaviour is important because these characteristics can change due to treatment and over time.

This review found that the associations of help-seeking behaviour with socio-demographic predisposing (e.g., age, gender, ethnicity, education, and family status), enabling (financial situation/income), need (e.g., severity of depression, comorbidity, and duration and number of episodes) and contextual factors were investigated in several studies. Gender, age, education, ethnicity, marital status, severity of depression, duration and number of depressive episodes, and comorbid anxiety disorders appeared to influence help-seeking behaviour. Further research investigating the influence of these characteristics on help-seeking behaviour by individuals suffering from major depression in prospective cohorts and research specifically focused on beliefs, social support, organizational factors and perceived need for treatment would address a significant gap in the literature. A better understanding of the process of help-seeking by individuals suffering from major depression and improved knowledge of the factors that influence this process are important for identifying groups at risk of failing to seek adequate professional help and for improving their access to depression care.

Supporting information

S1 appendix. prisma checklist..

https://doi.org/10.1371/journal.pone.0176730.s001

S2 Appendix. Search strategy.

https://doi.org/10.1371/journal.pone.0176730.s002

S3 Appendix. Inclusion criteria (IC).

https://doi.org/10.1371/journal.pone.0176730.s003

S4 Appendix. Quality characteristics.

Q1 and Q2 from the ‘Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” [ 29 ] Q3 from the Critical Appraisal Skills Programme [ 73 ].

https://doi.org/10.1371/journal.pone.0176730.s004

S5 Appendix. Summary of the main characteristics of the published articles.

ws = whole sample; MDE = major depressive episode; MDD = major depressive disorder; NR = not reported; DIS = Diagnostic Interview Schedule; WHO-CIDI / CIDI = World Health Organization’s composite international diagnostic interview; SFMD = Short form for major depression; SF = Short form; UM = Short Form (University of Michigan) ESEMeD = European Study on the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Study; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; CPES = Collaborative Psychiatric Epidemiology Survey; NSAL = National Survey of American Life; NCS = National Comorbidity Survey; NCS-R = National Comorbidity Survey–Replication; NLAAS = National Latino and Asian American Study; JUCSH = Joint Canada/US Survey of Health; NSDUH = National Study on Drug Use and Health; OHS = Ontario Health Study; ENHS = Ethiopian National Health Survey; NPHS = National Population Health Survey; ENHS = Ethiopian National Health Survey.

https://doi.org/10.1371/journal.pone.0176730.s005

S6 Appendix. Summary of results of the systematic review.

If adjusted and unadjusted results were reported in the same study for the same variable, only the adjusted results were listed in the table. + = significant positive association between characteristic and help-seeking behaviour;— = significant negative association between characteristic and help-seeking behaviour; Ø = no significant association between characteristic and help-seeking behaviour; x = significant differences between different groups; ESEMeD = European Study of the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Survey on Mental Health and Well Being; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; NSDUH = National Survey on Drug Use and Health; NCS = National Comorbidity Survey; OHS = Ontario Health Study; EHS = Estonian Health Survey; CPES = Collaborative Psychiatric Epidemiology Survey.

https://doi.org/10.1371/journal.pone.0176730.s006

Acknowledgments

This study as not funded and part of the dissertation of Julia Luise Magaard (JLM). However, Anna Levke Brütt (ALB), Tharanya Seeralan (TS) and JLM received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression. The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper. The authors declare that they have no competing interests. The authors wish to thank Mr. PD Dr. Levente Kriston for valuable and constructive comments on conduction of systematic reviews. We thank American Journal Experts (AJE) for English language editing.

Author Contributions

• Conceptualization: ALB HS JLM.
• Data curation: JLM TS.
• Formal analysis: ALB JLM TS.
• Funding acquisition: ALB.
• Investigation: JLM TS ALB.
• Methodology: JLM ALB HS TS.
• Project administration: ALB HS JLM.
• Resources: HS ALB.
• Supervision: HS.
• Validation: JLM ALB TS.
• Visualization: JLM TS.
• Writing – original draft: JLM.
• Writing – review & editing: ALB HS TS.
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